Don’t slouch. Don’t read in the dark. Don’t sit so close to the screen. These phrases sound so familiar because they were the litany of many mothers-which means we typically ignored them. But now, this same advice is coming from ergonomic experts whose council is taken more seriously. It turns out mom was right: We shouldn’t slouch, we shouldn’t read in the dark (or too bright light either), and we shouldn’t sit so close to the screen. Doing so can cause problems that result in pain and discomfort both on and off the job.
“As the medical imaging field transitions from film to digital, physicians are both figuratively and literally feeling the stress,” says Eliot Siegel, MD, professor and vice chair of information systems for the Department of Diagnostic Radiology at the University of Maryland School of Medicine (College Park, Md), and chief of radiology and nuclear medicine at the VA Maryland Healthcare System (VAMHS of Baltimore).
As more centers convert to digital and patient volume increases, more radiologists are exhibiting symptoms of repetitive strain disorders and other stresses that develop from working in a sedentary style, staring at a computer screen, and manipulating a mouse and keyboard for long periods of time. Hospitals are studying the problem and redesigning testing and reading rooms to make the environment more comfortable for radiologists and technologists.
For those within the facilities who have not yet taken these steps, experts suggest doing so independently. Siegel worked with Bruce Reiner, MD, director of radiology research at VAMHS and an associate professor at the University of Maryland School of Medicine, on a study1 in April 2002. Focusing on how to design a room, researchers found that a “redesign is likely to result in substantial improvements in reduction of fatigue, increased productivity, increased diagnostic accuracy, and possibly increased job satisfaction.”
Discomfort Becomes Disease
Radiologists share the same risks as anyone who sits at a computer for a large part of the day. “Studies have found carpal tunnel and cubital tunnel syndromes,” says Siegel, adding that radiologists also complain of shoulder, neck, and back pain as well as eyestrain.
“Usually these complaints come within the first few months,” says Greg Patrick, president of RedRick Technologies Inc (London, Ontario). “Some are complaints that come from being sedentary. Others, such as eye strain and fatigue, are more specific to their situation.”
Sue Tingey, worldwide marketing manager of healthcare imaging at Eastman Kodak Co (Rochester, NY), shares that anyone who spends more than 6-7 hours a day in front of the computer is susceptible to carpal tunnel syndrome. No specialty is immune. A study published in Ergonomics2 found that a majority of X-ray technologists had suffered multiple episodes of pain. Half of the female sample (9 of 18) and both males in the study suffered upper extremity pain. Of the full sample population, 83% complained of backaches.
Another study looking at sonographers3 found that 88.5% reported work-related symptoms. According to the study, which was published in the International Journal of Industrial Ergonomics, “Three clusters of symptoms emerged from the data: neck and interscapular pain; shoulder or upper arm pain, elbow pain, clumsiness of the fingers, and numbness or tingling; and frontal headaches and visual disturbances.”
Yet another study,4 published in the American Journal of Roentgenology, determined that “current technology renders staff radiologists at risk for work-related, upper extremity musculoskeletal disorders, including carpal and cubital tunnel syndromes.”
The risks are not shared evenly. The sonography study found that proportionally, more women than men had experienced work-related symptoms. In addition, those with work-related symptoms were slightly shorter and slightly lighter in weight than those without work-related symptoms.
The consequences extend past physical discomfort into the psychological realm. A survey of 90 radiologists, fellows, and residents at Indiana University5 found that overall satisfaction with the soft-copy environment was low, with nearly half of the 55 respondents (46%) rating themselves as “very dissatisfied” or “dissatisfied.” The respondents were least satisfied with work space ergonomics, room layout, and the amount of work space. They also cited lighting as a source of dissatisfaction.
Simple changes can affect the bottom line. Happier radiologists tend to be more productive. In the study at Indiana University,5 98% of respondents indicated that an “ideal” soft-copy environment would have a positive effect on their efficiency. Another study6 found that workflow reengineering associated with the use of PACS resulted in increased efficiencies of 20%-60% for the technologists, more than 50% for the clerical staff, and more than 40% for the radiologists.”
“I have no doubt that a small investment in ergonomic redesign will increase efficiency and productivity,” Siegel says. “Film-based reading rooms are not adequate for digital radiology. The resulting problems make it difficult for radiologists to work during the day, with decreased productivity and increased absenteeism.”
In response to the consequences of ergonomic-related problems experienced by members of radiology departments, many facilities have sought to redesign these workstations to decrease risks and increase comfort. “Many institutions have brought in teams to evaluate the needs of the department,” says Ron Muscosky, product line manager of healthcare imaging at Eastman Kodak Co. “A room needs to be tailored to the site and the users.”
According to the authors of the study “Importance and Effects of Altered Workplace Ergonomics in Modern Radiology Suites,” optimization of workplace ergonomics should be considered in the basic design of any modern radiology suite.7 “Design should consider the workflow, the number of users, the items to be used, and with what frequency,” says Amir Ratlevi, director of AFC Industries Inc (College Park, NY).
RedRick’s Patrick says, “Some of the recommendations are old in ergonomic literature but new to radiology,” and he cites the ability to adjust desks, monitors, and keyboards as examples. Others apply to the general atmosphere of the reading room, such as lighting and sound.
Bryant Furlow, a Northern California-based science writer, says, “Equipment manufacturers like to label merchandise ‘ergonomic,’ but because ergonomic fit varies between individuals, it’s misleading. Truly ergonomic equipment is designed to allow personalization of use-adjustable heights, tilt, and back and arm support.”
Muscosky concurs, adding, “The notion of an average user is a myth.” He cites two areas for personalization: the workstation and the input devices.
In the Siegel and Reiner study, which focused on how to design a room, these aspects were broken down further. The authors note that with the advent of PACS, radiologists are no longer tied to a reading room but can access files at any PACS workstation. The design in some of these areas, such as the emergency room, might not be as flexible as in the radiology department, but physicians should still make the effort to adjust their work space.
“Important principles for workstations, or any workplace, include personalizing equipment configuration or layout at the outset of each use,” Furlow says. “Adjust monitors and seat heights so that each workstation user is sitting upright with a straight back and feet flat on the floor. The monitor should be at eye level, and the angle between the upper arm and forearm should be between 70? and 135?. If fixed-height workstation desks and monitors are used, it’s important that vertically adjustable keyboard trays be installed. Workstations should be organized with the most commonly used items within easy reach.”
Ratlevi agrees that work spaces should be as flexible as possible. Adjustability is key. But so is workflow.
Unfortunately, keeping within easy reach those items and functions that are likely to be used may be a greater challenge than one would at first think. Radiologists at the Baltimore VA, the subjects of the Siegel and Reiner study, required access to the PACS workstation, the Internet and intranet, a speech-recognition or digital dictation system, the hospital’s “paperless” electronic medical records, email, office software, and the telephone. The integration of all of these functions into a single, multitasking workstation, with easy access to all of the features on demand, would not only increase the comfort for users but would also increase efficiency and productivity.
Such a workstation would be of greater value than a large, central reading room, which studies have found to become obsolete as digital imaging has become the norm. This transition has brought attention to corresponding changes in lighting, sound, temperature, and ventilation.
According to Siegel, lighting is particularly important; poor lighting can have a negative effect on fatigue and eyestrain. A balance must be found between the monitor light and the ambient background lighting to reduce glare. “Newer generation LCD monitors feature less electromagnetic radiation, less heat, less flicker, less glare, and brighter light, resulting in less strain and fatigue for users,” he says.
Siegel and Reiner’s study found that “decreased radiologist productivity, decreased accuracy, and increased fatigue levels were seen when using monitors that were less bright compared to those with higher luminance.” In order to improve ambient light in the radiology reading environment, four primary objectives need to be addressed: general illumination levels for computer tasks; illumination for reading tasks using localized light sources; the balance of brightness levels in the user’s field of view; and control of monitor reflection. “In order to accomplish these objectives,” the study concluded, “a combination of indirect overhead lighting and local task lighting, using dimmable sources, can be used to provide maximum flexibility for each radiologist.”
Sound also can be a source of stress. Computer workstations generate a good deal of background noise as do telephone calls, ventilation fans, the overhead hospital paging system, and the dictation of other radiologists.1 Siegel suggests that carpeting and wall panels can reduce sound reflection and dampen noise.
Additionally, the temperature and ventilation can bring negative stress. Siegel and Reiner found that the increase in computer equipment caused the temperature in the reading room to rise; subsequently, within 3 months, the radiologists using the room took more frequent and longer coffee breaks to get away. “Our experience underscores the importance of adequate planning for air conditioning and ventilation in the reading rooms,” the authors concluded.
And just as the atmosphere can affect a physician’s productivity, so can the input devices. “When developing specialized or custom devices, we consider the size of the user’s hand, task frequency, and activation pressure,” Muscosky says.
Frequently used buttons should be easily accessible, and the pressure required to activate them should be light. Innovative devices include a two-piece hand controller mounted on the desk, joysticks, game controllers, and foot pedals. Items that eliminate movement altogether are also in development. Muscosky shares that Kodak is investigating voice commands.
Use or Lose
If the new equipment is to bring any benefit, users must adapt to it. “It’s always difficult to change one’s routine. Some modifications are easier to adapt to than others,” says Siegel, citing the use of an LCD monitor as an easier adjustment than using a new input device, which might not even be a vendor option.
“Most radiologists who have experienced problems already are more receptive to incorporating changes,” Muscosky notes.
RedRick’s Patrick says that now is an excellent time to make modifications. “Many facilities are making the transition from film to digital,” he says. “And because everything is changing, it’s an ideal time to integrate new ergonomic equipment and techniques.” Making changes before the radiologists develop new habits in front of the computer can prevent the injuries that result from stress and strain.
Also, radiologists themselves can assume responsibility for prevention and incorporate changes on their own. Siegel recommends the “20-20-20” rule. “Computer users should look 20 feet away from the computer for 20 seconds every 20 minutes,” he says. Patrick suggests users get up every 30 minutes, or at least look away from the computer.
And everyone should, of course, take the time to adjust the workspace to his or her body. “Most places have multiple users, and adjustments need to be made quickly,” says AFC’s Ratlevi.
Siegel envisions a future where workspaces are adjustable with the push of a button, similar to the function currently available in some high-end automobiles. But what if the facility has not invested in ergonomic equipment? Siegel suggests that users make their own investments. “Radiologists will sit in a bad chair without complaining,” he says. “For less than $1,000, they can buy a good chair with the benefit felt immediately.”
Patrick also suggests off-the-shelf lighting. “It’s fairly easy to find something that produces a level of light equal to the monitor’s level of light and that reduces glare,” he says.
Finally, one study concludes that “paying close attention to the basics of workplace ergonomics can go a long way in increasing productivity and reducing fatigue, thus allowing full realization of the potential benefits of a PACS.”6 Or in more familiar words: Don’t slouch. Don’t read in the dark. Don’t sit so close to the screen. You wouldn’t want to go blind, would you?
Renee DiIulio is a contributing writer for Medical Imaging.
- Siegel E, Reiner B. Radiology reading room design: the next generation. April 2002. Available at: http://www.eisysinc.com/pacs/downloads/
room%20 design%20the%20next%20generation.pdf. Accessed October 27, 2004.
- Kumar S, Moro L, Narayan Y. Perceived physical stress at work and musculoskeletal discomfort in X-ray technologists. Ergonomics. 2004;47(2):189?201.
- Wihlidal LM, Kumar S. An injury profile of practicing diagnostic medical sonographers in Alberta. Int J Ind Ergonomics. 1997;19(3):205?216.
- Ruess L, O’Connor SC, Cho KH, Hussain, FH, Howard WJ, Slaughter RC, et al. Carpal tunnel syndrome and cubital tunnel syndrome: work-related musculoskeletal disorders in four symptomatic radiologists. AJR Am J Roentgenol. 2003;181(1):37?42.
- Rumreich LL, Johnson AJ. From traditional reading rooms to a soft copy environment: radiologist satisfaction survey. J Digit Imaging. 2003;16(3):262?269.
- Moise A, Atkins MS. Design requirements for radiology workstations. J Digit Imaging. 2004;17(2):92?99.
- Harisinghani MG, Blake MA, Saksena M, Hahn PF, Gervais D, Zalis M, et al. Importance and effects of altered workplace ergonomics in modern radiology suites. Radiographics. 2004;24:615?627.
The Subject of Sonography
Congratulations to Philips Medical Systems (Andover, Mass) and its iU22 ultrasound system. In an independent study1 that compared six ultrasound systems, the iU22 was named the best overall at ergonomic accommodation for sonographers. Want more information about ergonomics issues specific to ultrasound? Don’t miss Gordon Parhar’s Guest Editorial, “Ultrasound Ergonomics: Designed with the Sonographer in Mind.”
The Choice Is Yours
Along with increases in productivity and workflow efficiency, the transition to digital imaging also has brought increases in ergonomic-related injuries for users. The latter can be counterproductive to the former, as facilities are quite aware. In recognition, many facilities are redesigning their medical imaging departments to decrease workplace stress and fatigue as well as increase productivity and employee satisfaction.
The key is adjustability-users should have it their own way, and many new products out there offer just that.
AFC Industries Inc
(College Point, NY)
Sound Ergonomics LLC