When a radiologist is tired, what kind of impact can that have on their overall performance? What can they do to avoid feeling so tired, other than gulp an extra cup of coffee or two?

Elizabeth A. Krupinski, PhD, professor and vice chair for research at the Emory University School of Medicine’s department of radiology and imaging sciences, has been studying fatigue in radiology for a decade now. At RSNA 2016, Krupinski will present information on some of what she’s learned during the three-part “Perception in the Clinic” session on Friday, Dec. 2.

Krupinski spoke with Radiology Business about her presentation, what sparked her interest in the topic, and where her research is taking her next.

What about the subject of fatigue in radiology first gained your interest? Why do you think this is so important?

Elizabeth A. Krupinski: A lot of the work I do is trying to understand why radiologists make errors, what contributes to their expertise, what can enhance training, what can improve decision making, and so on. As a part of that, I do eye tracking studies where I bring radiologists in my lab and I track where they look. So I noticed, about 10 years ago, that I would bring radiologists in late in the afternoon and I would have trouble getting the signal from their eyes needed for eye tracking. It dawned on me that they were tired; their eyes were drooping, but to do eye tracking, the eyes need to be wide open.

If they’re tired in my lab, I thought, perhaps they are tired in the clinic as well. I started to read the literature—and there really wasn’t a lot out there on fatigue in radiology—and I thought, well, if the radiologists and residents are fatigued, does this impact their ability to make decisions?

 This is important, because if we do discover that they are making errors as they get more fatigued, than that is impacting patient care. You don’t want your lesion to be missed because your radiologist was tired at the end of the day.

So about eight years ago, we started to investigate this topic. Could we document that diagnostic accuracy is impacted by fatigue? Could we discover the physiological and/or cognitive reasons behind that decline?

What have you learned so far? What happens to a radiologist when he or she is tired while on the job?

We used something called the Swedish Occupational Fatigue Inventory, which is a validated survey used to assess fatigue and stress in a work environment. It’s not specific to radiology, but this is a validated survey. We had radiologists and residents come in and fill out surveys  in the morning and in the afternoon and, yes, they felt tired after a long day of clinical work.

So subjectively, they’re fatigued; that’s not surprising. But could we find some sort of physiological correlate? The natural thing to do, since radiologists view images, was to look at their visual system. We were able to demonstrate, with a few different measurements, that after eight hours of work, radiologists and residents were significantly less able to focus on a point about 18 inches away, which is the normal monitor viewing distance for radiologists. So that ability to focus was significantly impaired.

In addition, we’ve developed a series of performance studies—looking at bone fractures, finding nodules in chest images, finding nodules in CT chest images—and these have demonstrated a decrease of about 4 percent in diagnostic accuracy when the radiologists are tired. thTese are all studies in the laboratory, but our hypothesis is that if we see it in the lab, it’s likely taking place in the clinic as well.

Does fatigue in radiology lead to radiologist depression and/or burnout? Are they all part of the same conversation?

I think they are. There is more and more pressure on radiologists to view and interpret more images in a shorter amount of time. It’s that bottom line of RVUs; you have to read so many cases in a day or you fall behind. That part is very fatiguing, and some find it frustrating or disheartening. You might feel like a rat in a cage or a hamster on a wheel, if you will. There are clear ties between fatigue and depression in general, so I don’t see why that wouldn’t be the case in radiology as well - and both fatigue and depression can lead to burnout.

What can radiologists do to avoid being fatigued?

A lot of it is common sense, but it’s also about setting priorities. For example, in mammography, you could do all of your image interpretations in the morning when you are fresh and then do your procedures later in the day when you are more physically active and ready to do something different. For specialties where you’re really just interpreting images all day, maybe take time out on a periodic basis to get up and walk away to do something else. Get your eyes off that screen. There’s also something called a 20-20-20 rule: every 20 minutes, take 20 seconds to look at something 20 feet away. That isn’t going to work all the time, but if you do it throughout the day, it certainly could help.

On top of that, it’s important to recognize when you are becoming fatigued. Truck drivers, for example, have  technology that monitors their eyes and can tell when the eyes are beginning to droop. It sets off an alarm and tells the drivers to take a break, and in some cases, I think the system even notifies a manager. Something like that could be implemented on a radiologist’s workstation.

You can utilize certain tools and support systems radiologists have available. Properly optimize your monitor to the right resolution and brightness, set ambient lights to the proper level, use workstations that move up and down to allow standing and sitting, or take advantage of decision support tools. There are an awful lot of things you can do, not to avoid being fatigued, but to ameliorate some of the effects.

What’s next for your research?

We’re now investigating the satisfaction of search phenomenon and whether fatigue impacts it. When you have more than one abnormality in an image, you may find one and then say you are satisfied and quit searching; this is a well-known cause of errors, and fatigue has been documented as another cause of errors. So what if you’re tired and there are more than one lesion? That’s the study we are running now, and we’ll discuss it at RSNA as well.

This text has been edited for space and clarity.