Against the backdrop of radiologists getting sued for medical negligence after allegedly reading images too hastily, recent years have seen calls to nationally mandate limits on rads’ workload volumes, reading speeds and on-duty hours. The authors of a new literature review challenge the wisdom of formalizing such requirements.
The analysis was conducted at SUNY Downstate Health Sciences University in Brooklyn, N.Y., and published June 14 in Radiology [1].
Corresponding author Stephen Waite, MD, and colleagues cite several papers in the pro-mandate literature. Among these is a 2021 opinion piece written by the prominent radiologist Frank Lexa, MD, MBA, and published in JACR [2].
In that paper, Lexa, chief medical officer of the ACR’s Radiology Leadership Institute and professor and vice chair of faculty affairs in radiology at the University of Pittsburgh School of Medicine, wrote:
I propose that national radiologist workload limits and duty rules should be set to optimize radiologists’ performance and to protect their health and professional longevity. These limits should be scientifically based and would include a maximum shift length of 10 hours, with an hourly limit based on the type of case or cases being read. … We would not be the first group of professionals to take these difficult steps; the actions of the aviation industry, among others, showed that although difficult, these types of reforms were the right choice for safety.”
A primary plank in the counterargument offered by Waite et al. is the very lack of a scientific basis that would support such specialty-wide limits.
“Although long shifts and so-called off-hours work may sometimes lead to poor performance and serve as a source of medical error, to the authors’ knowledge, no research to date has provided the evidence necessary to establish appropriate limits for individual radiologists,” Waite and co-authors write.
Waite and colleagues flesh out numerous points that, in their view, ought to collectively suggest fixes to radiologist haste—real, perceived or both—other than mandated limits on workload, duty and speed. These include:
1. Scene processing in less than a second does not indicate carelessness or recklessness but, in some settings, can be characteristic of competent or expert visual processing.
In baseball, the time from the pitch until the bat strikes the ball can be less than 0.5 seconds, [and] expert batters discriminate between different types of pitches in under 200 milliseconds ... Indeed, in many contexts, scene processing in less than a second does not indicate carelessness or recklessness. Rather, it is consistent with efficient and successful processing of stimuli, such as when experts perform a trained oculomotor task.”
2. It is unknown how many examinations or images radiologists can review in any period while maintaining accuracy.
Unprincipled regulations can worsen performance for radiologists who perform at their peak while near the margins of normal performance parameters, resulting in inadvertent exacerbation of medical error and compromised patient care. … Before principled recommendations for restrictions are made, however, it is important to understand how radiologists function both optimally and at the margins of adequate performance.”
3. Caseload reduction wouldn’t necessarily mitigate error.
[I]t is often assumed that increasing case volume directly results in less reading time per study, thus increasing error. In some cases of extreme time pressure, this is unequivocally true: Reduced viewing time can lead to error. … However, this pattern is not linear: In some experimental settings, performance with 4 seconds is similar to unlimited viewing time. … [Some research has shown that] artificially slowing down radiologists’ reading times could cause them to second-guess correct findings or seek new and incorrect interpretations, thus leading to new errors.”
4. Shift duration limits would have similarly suspect effects on fatigue levels and error rates.
Even if fatigue is a likely source of error in radiology, its effects may be ameliorated without arbitrary time restrictions. For example, hourly breaks decrease eye strain in radiologists. Other measures to reduce fatigue focus on optimizing the ergonomic design of the reading environment, such as by increasing ambient lighting and eliminating glare. … Ensuring that other colleagues are present at the end of long shifts could reduce error by enabling fatigued radiologists to obtain consultations and second readings.”
5. AI can help, but it will remain a clinical work in progress for some time to come.
[S]tudies that examine the impact of AI tools on radiologists’ decisions and the ultimate effects of AI tools on patient care and outcomes are lacking. … [That said,] considerable research and development efforts regarding AI and machine learning tools are underway and this technology is promising. Combining AI and radiologist assessment can improve accuracy compared with human interpretation alone and is a feasible solution to directly addressing errors of interpretation, including errors from fatigue, high caseloads, and off-hours shifts.”
Calling for future studies to better understand how radiologist performance changes with different workloads, expertise, fatigue and time of day, Waite and co-authors concede that, at some point, regulation may indeed be required.
However, at present, “making rules without reliable scientific evidence is unprincipled and may fail to address the underlying problem (eg, the 80-hour resident work-hour rule has not resulted in decreased medical error), but it can create additional unforeseen problems such as an unacceptable backlog of unread images,” they state. “Unprincipled regulations can worsen performance for radiologists who perform at their peak while near the margins of normal performance parameters, resulting in inadvertent exacerbation of medical error and compromised patient care.”
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References:
- Robert Alexander, Stephen Waite, Michael Bruno, Elizabeth Krupinski, Leonard Berlin, Stephen Macknik, Susana Martinez-Conde: “Mandating Limits on Workload, Duty, and Speed in Radiology.” Radiology, June 14, 2022. DOI: https://doi.org/10.1148/radiol.212631
- Frank Lexa, “Duty Hour Limits for Radiologists: It’s About Time.” Journal of the American College of Radiology, Jan. 1, 2021. DOI: https://doi.org/10.1016/j.jacr.2020.06.019
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.