Association of work-related stress with depression and anxiety in radiologists.

PURPOSE: Since radiologists and radiotherapists can be occupationally exposed to significant psychosocial risk factors, some may find themselves in a state of distress. The aim of this study was to investigate the association of work-related stress with the presence of symptoms of anxiety, depression and psychological malaise and to evaluate the risk of psychic disorder in radiologists suffering from work-related stress. METHODS: A total of 654 radiologists responded to our invitation to complete a questionnaire designed to evaluate work-related stress and associated medical conditions: the General Health Questionnaire and Goldberg's Anxiety and Depression scales. RESULTS: Scores on the anxiety, depression and psychological malaise scales rise with an increase in effort and over-commitment, while control and support exert a protective effect. In radiologists who are aware of an effort/reward imbalance, there is a marked increase in the risk of anxiety [odds ratio (OR) 14.14, 95 % CI 9.15-21.86], depression (OR 7.00, 95 % CI 4.76-10.30) and psychic disorders (OR 3.95, 95 % CI 2.62-9.57). Radiologists who perceive demand as excessive in relation to their power of control also have an increased risk of being anxious (OR 2.98, 95 % CI 2.05-4.31), depressed (OR 1.73, 95 % CI 1.21-2.48) and affected by psychic disorders (OR 2.26, 95 % CI 1.48-3.45) compared to fellow workers who are not in a state of distress. CONCLUSIONS: Outstanding technical progress has been made in the field of radiology which today plays an invaluable role in public health. Now a major effort must also be made to improve the mental wellbeing of radiologists, both in the interests of the workers themselves, and also in those of their patients and the quality of the treatment they have the right to receive.

Malpractice claims in interventional radiology: frequency, characteristics and protective measures.

PURPOSE: The use of interventional radiology procedures has considerably increased in recent years, as has the number of related medicolegal litigations. This study aimed to highlight the problems underlying malpractice claims in interventional radiology and to assess the importance of the informed consent process. MATERIALS AND METHODS: The authors examined all insurance claims relating to presumed errors in interventional radiology filed by radiologists over a period of 14 years after isolating them from the insurance database of all radiologists registered with the Italian Society of Medical Radiology (SIRM) between 1 January1993 and 31 December 2006. RESULTS: In the period considered, 98 malpractice claims were filed against radiologists who had performed interventional radiology procedures. In 21 cases (21.4%), the event had caused the patient's death. In >80% of cases, the event occurred in a public facility. The risk of a malpractice claim for a radiologist practising interventional procedures is 47 per 1,000, which corresponds to one malpractice claim for each 231 years of activity. DISCUSSION: Interventional radiology, a discipline with a biological risk profile similar to that of surgery, exposes practitioners to a high risk of medicolegal litigation both because of problems intrinsic to the techniques used and because of the need to operate on severely ill patients with compromised clinical status. CONCLUSIONS: Litigation prevention largely depends on both reducing the rate of medical error and providing the patient with correct and coherent information. Adopting good radiological practices, scrupulous review of procedures and efficiency of the instruments used and audit of organisational and management processes are all factors that can help reduce the likelihood of error. Improving communication techniques while safeguarding the patient's right to autonomy also implies adopting clear and rigorous processes for obtaining the patient's informed consent to the medical procedure.

Violence against radiologists. I: Prevalence and preventive measures.

PURPOSE: Violence in the workplace is a specific risk for healthcare workers. Radiologists, especially when involved in emergency services, share that risk. Very few studies in the literature have researched this topic. This study aimed to evaluate the prevalence of violent behaviour in a large sample of Italian radiologists and analyse the phenomenon and its consequences with a view to proposing preventive measures. MATERIALS AND METHODS: A total of 992 radiologists (61.5% men) taking part in a national radiology congress agreed to respond to a questionnaire on violence that contained the Violent Incident Form by Arnetz for the description of violent incidents in healthcare practice. RESULTS: Some 6.8% of radiologists in public hospitals experienced physical abuse in the previous 12 months, for the most part from patients or their companions. The prevalence of physical abuse is greatest among younger healthcare individuals with less clinical experience, with no differences between sexes. Among younger radiologists, one in five suffered at least one act of physical abuse in a working year. Nonphysical violence is more widespread and throughout radiologists' working lives affects 65.2% of them. In this case, almost half of the violent incidents originate from colleagues. A total of 5.5% of respondents stated that they were victims of abuse at the time of the survey. In most cases, the violent incidents remain unreported. The immediate consequences of violence in the workplace are emotions such as anger, disappointment, humiliation, anxiety, fear, distress, a feeling of helplessness and isolation, occasionally a feeling of guilt or of having done wrong and a desire to take revenge, change behaviour or change workplace. CONCLUSIONS: The extent of the problem calls for the adoption of a series of measures aimed at eliminating the causes of the various forms of workplace violence.

Violence against radiologists. II: Psychosocial factors.

PURPOSE: Violence against radiologists is a growing problem. This study evaluated the psychosocial factors associated with this phenomenon. MATERIALS AND METHODS: A questionnaire was administered to 992 Italian radiologists. RESULTS: Physical violence experienced in the previous 12-month period was associated with the radiologist's poor mental health [odds ratio (OR) 1.11] and overcommitment to work (OR 1.06), whereas radiologists in good physical health (OR 0.64), with job satisfaction (OR 0.96) and with overall happiness (OR 0.67) were less exposed. Nonphysical abuse was equally associated with the radiologist's poor mental health (OR 1.10) and overcommitment (OR 1.14) and negatively associated with physical health (OR 0.54), job satisfaction (OR 0.96), happiness (OR 0.81), organisational justice (OR 0.94) and social support (OR 0.80). CONCLUSIONS: Preventive intervention against violence in the workplace should improve workplace organisation and relationships between workers.

Clinical Risk Management in radiology. Part II: applied examples and concluding remarks.

With the aim of providing a clearer understanding of the tools used for evaluating risk in the radiological setting and how they are applied, this second part presents two practical examples. The first is a proactive analysis applied to CT, whereas the second is a reactive analysis performed following a sentinel event triggered by a CT study allocated to the wrong patient in the RIS-PACS system.

Clinical Risk Management in radiology. Part I: general background and types of error and their prevention.

The present contribution, presented as an Editorial, addresses the issue of patient safety in Radiology: this topic, of great current National and Regional interest, has stimulated a strong focus on accidents and mistakes in medicine, together with the diffusion of procedures for Risk Management in all health facilities. The possible sources of incidents in the radiological process are exposed, due to human errors and to system errors connected both to the organization and to the dissemination of Information Technology in the Radiological world. It also describes the most common methods and tools for risk analysis in health systems, together with some application examples presented in Part II.

Satisfaction at work among radiologists.

PURPOSE: This study sought to evaluate professional satisfaction among Italian radiologists and identify what personal characteristics of radiologists and features of their work and work setting affect job satisfaction. MATERIALS AND METHODS: Satisfaction was assessed by using Warr et al.'s 17-item Job Satisfaction Scale (JSS) in 206 radiologists, 108 radiotherapists and 34 specialists in infectious diseases used as controls. RESULTS: Forty-nine per cent of diagnostic radiologists reported being satisfied with their jobs. The frequency is significantly lower than that found among radiotherapists (64%) and controls (62%). Middle-aged radiologists on lower rungs of the career ladder were more dissatisfied than were their older colleagues in top positions. Female radiologists were less satisfied than their male counterparts with regard to recognition for good work, amount of job variety and distribution of workloads. Stepwise logistic regression analysis showed that job satisfaction was especially affected by physical working conditions, freedom to choose one's own work method, relationship with one's immediate boss, attention paid to one's suggestions and the amount of job variety. CONCLUSIONS: This pilot study identified the sources of professional satisfaction and dissatisfaction among radiologists. A future survey of a stratified random sample of Italian radiologists appears to be feasible.

Ethical problems in radiology: medical error and disclosure.

In radiological practice, as in any medical activity, errors are inevitable despite being foreseeable and preventable. The approach to managing medical error and relations with patients prompt the need for resolving the ethical dilemma arising from conflicting legitimate interests. The solution to this dilemma is particularly complex in an environment in which the tendency to sue physicians for civil liability or incriminate them for criminal liability appears to be particularly high. The disclosure of error is undeniably useful in raising patient awareness, reducing their suffering, improving the quality of care and limiting the consequences of the damage. There does not appear to be any evidence to suggest disclosure modifies the probability of litigation against the physician.

Analysis of malpractice claims in mammography: a complex issue.

PURPOSE: The aim of this study was to analyse malpractice claims in mammography, estimate the specific risk of future claims and assess their impact on radiologists and society. MATERIALS AND METHODS: The study considered insurance claims filed by radiologists of the Italian Society of Medical Radiology (SIRM) over a 12.5-year period between 1 January 1993 and 30 June 2005. We isolated claims related to presumed diagnostic errors in mammography. We then estimated the number of claims arising from events in the study period that are expected to be filed over the next few years, before the expiration of the prescriptive period of 10 years. RESULTS: The total number of claims was 1,088. Of these, 302 were caused by alleged diagnostic errors in cases of cancer; 189 (62%) concerned breast cancers and mammographic technique. Assuming a constant frequency of claims filed by radiologists, we expect a further 637 claims relating to the study period, for a total of 1,725 claims, with 178 claims being related to breast imaging. The predicted rate therefore increases to 10.5 per thousand, equal to a risk of one litigation per radiologist per 10 years of work. CONCLUSIONS: The analysis uncovered a complex problem: although radiologists save many lives through the radiographic diagnosis of breast cancer and consequently contribute to the welfare of society, in practice, they can face real or alleged errors, with serious judicial consequences. Awareness of professional risk in current society may represent a valuable reference for choosing and planning to work in radiology.

The legal implications of error in radiology.

Evaluation of the legal implications of error in radiology and therefore the assessment of criminal and civil liability in the practice of the profession requires an analysis of how the public perception of the right to health has radically changed. This change has initiated a defensive approach to medicine and radiology that tends to be oriented towards precautionary measures, with a proliferation of often unnecessary imaging studies. In radiology, errors of omission or commission are frequent. A critical appraisal of the different types of error in radiology will help practitioners undertake the essential corrective measures. Through analysis of several cases derived from legal or insurance proceedings brought against radiologists, the most common forms of error are described, and their implications for criminal and civil liability are illustrated, although it is emphasised that the existence of an error does not always translate into the presence of malpractice.

Work stress in radiologists. A pilot study.

PURPOSE: We studied occupational stress and its psychosocial effects in a sample of Italian radiologists and radiotherapists: MATERIALS AND METHODS: Radiologists and radiotherapists attending two medical conferences were invited to complete a questionnaire comprising four sections investigating the risk of occupational stress (organisational discomfort, Karasek's Job Content Questionnaire, Siegrist's Effort-Reward Imbalance, Warr's Job Satisfaction) and four sections investigating the health effects of such stress (Goldberg's Anxiety and Depression Scales, General Health Questionnaire, Lifestyles Questionnaire). RESULTS: Radiologists and radiotherapists generally expressed high levels of control, reward and satisfaction. However, 38.5% complained of severe organisational discomfort, 24% reported job strain, 28% reported effort/reward imbalance and 25% were dissatisfied. Female radiologists and radiotherapists showed higher levels of organisational discomfort than their male colleagues. Younger and less experienced radiologists and radiotherapists had higher strain scores than their older and more experienced colleagues. A significant correlation was observed between stress predictors and the effects of stress on health, including depression and anxiety, psychological distress and unhealthy lifestyles. CONCLUSIONS: Radiologists and radiotherapists are exposed to major occupational stress factors, and a significant percentage of them suffer from workplace stress. A special effort is required to prevent this condition.

Malpractice stress syndrome in radiologists and radiotherapists: perceived causes and consequences.

PURPOSE: Radiology is among the specialties with an increasing risk of litigation. Regardless of the outcome of legal proceedings, physicians who are sued usually perceive the claim as an assault on their integrity and may suffer psychological or physical effects known as "malpractice stress syndrome". MATERIALS AND METHODS: Two hundred and six radiologists and 108 radiotherapists responded to a questionnaire containing specific items concerning their perception of malpractice stress and their opinions about the causes of clinical errors, as well as an assessment of work satisfaction and general health. RESULTS: One third of physicians had been sued for malpractice. Age was significantly related to the occurrence of malpractice litigation. Radiological errors were purportedly related to occupational discomfort, and the latter variable was significantly associated with work dissatisfaction and a low level of psychological and physical well-being. CONCLUSIONS: Radiologists are well acquainted with medical malpractice and its causes; however, they have limited familiarity with clinical risk management practices and often ignore procedures of informed consent. A targeted educational effort is required to overcome these shortcomings.

[Job satisfaction. Use of the Job Satisfaction Scale (JSS)]. / Soddisfazione da lavoro. Uso della Job Satisfaction Scale (JSS).

Job satisfaction is an important determinant of wellbeing and a moderator of stress at work. The Warr's Job Satisfaction Scale (JSS) is probably the most used questionnaire to assess job satisfaction. The aim of this paper is to evaluate the Italian version of the JSS. The questionnaire has been distributed to 632 health care workers. Results show that the Italian version of JSS has good reliability (Cronbach's alpha = 0.94). Principal component analysis revealed that a significant percentage of the variance (52%) was explained by a single factor which included all the 16 items. Varimax orthogonal rotation yielded the same two factors observed in the original questionnaire: intrinsic and extrinsic job satisfaction. The JSS may be an useful tool in the assessment of psychosocial risk at work.

[Critical aspects of the management of "hazardous" health care workers. Consensus document]. / Aspetti critici della gestione dei "lavoratori rischiosi" nei servizi sanitari. Documento di consenso.

BACKGROUND: A worker is considered to be hazardous to others when, in the course of performing a specific work task, his/her health problems (e.g., substance dependence, emotional disorders, physical disability, transmissible diseases) pose a risk for other workers' or the public's health and safety, or begins to interfere with ability to function in profession life. The presence of certain illnesses or the fact that a health care worker is impaired because of them do not necessarily imply that he, or she, is hazardous for others. Working in health care increases the probability that an impaired worker being hazardous for others. Management of hazardous workers requires new techniques and procedures, and specific policies. OBJECTIVE AND METHODS: An interdisciplinary group of experts from medical, bioethical, legal and administrative disciplines, together with trade union and employers' representatives, is currently attempting to define a way to put prevention measures into practice in accordance with state laws and individual rights. RESULTS: A consensus document is presented, covering critical aspects such as: social responsibility of the employer, risk management, informed consent, non compliance, confidentiality, responsibility of workers, disclosure of risk to patients, non-discrimination, counselling and recovery of impaired workers, effectiveness of international guidelines. CONCLUSIONS: Occupational health professionals are obliged to adhere to ethical principles in the management of "hazardous" workers; the assessment of ethical costs and benefits for the stakeholders is the basis for appropriate decisions.

A 12-year follow-up study of malpractice claims against radiologists in Italy.

PURPOSE: Malpractice claims filed against radiologists have become a relevant phenomenon in Italy and are a real risk in the radiologists' professional activity. MATERIALS AND METHODS: Insurance claims of Italian radiologists over the 1993-2004 period were anonymously assessed. A total of 990 insurance claims were classified according to cause: (1) missed diagnosis, (2) complications of the radiological procedure, (3) failure to order further radiological examinations, (4) radiation treatment, (5) slip-and-fall injuries, (6) miscellaneous causes. RESULTS: A total of 990 claims were filed during the period, with most claims being filed a considerable time after the event. As a consequence, the estimated incidence may be 44 per 1,000. In other words, 44% of Italian radiologists have received, or will receive, a summons regarding their professional activity of the past 10 years. Misdiagnosis made up the first and most important claim category. Missed abnormalities on breast radiographs accounted for the greatest percentage of cases. Missed bone abnormalities were the following most common diagnostic errors. Complications following interventional procedures accounted for 10% of all cases. A few cases resulted from the radiologist's failure to order further diagnostic examinations. Lastly, radiologists were frequently named as one of multiple defendants, together with medical (or surgical) doctors, in cases of patient death in roughly 6% of all cases. CONCLUSIONS: The risk of medical malpractice litigation for Italian radiologists is by now comparable to that for American radiologists. Strict adherence to radiological standards may be a means of reducing the risk of legal action and obviating litigation.

[Identification and control of workers that pose a risk to others in the health field]. / Identificazione e controllo dei lavoratori rischiosi per gli altri nelle attività sanitarie.

BACKGROUND: Working in health care increases the probability that an impaired worker be hazardous for third persons. METHODS: A literature review concerning identification, intervention, and treatment of hazardous health care workers is here reported. RESULTS: Published reports of health care worker-to-patient transmission of bloodborne infections, and papers concerning the so-called "impaired physician", have been reviewed. DISCUSSION: According to European directives on workers' health and safety, the occupational health physician charged of medical surveillance of hospital workers is often mandated to manage impaired professionals. CONCLUSIONS: Strategies for early identification, treatment and rehabilitation of impaired physicians are reviewed and suggestions for preventive action are given.

Risk management in radiotherapy: analysis of insurance claims.

PURPOSE: The purpose of this study was to analyse risk factors in radiotherapy with regard to those where protocols have been implemented for their prevention and those that are known but still present, thus requiring attention and remedial measures. MATERIALS AND METHODS: To demonstrate the existence of risk factors that have not been eliminated and that cause damage in radiotherapy practice, we examined insurance claims related to such radiotherapy procedures. Analysis of the claims made over a 10-year period was performed on the basis of radiotherapists (256 in 2004) insured with the professional association. The total number of claims in the 10-year period was 26. RESULTS: The type of claim was examined in each of the 26 cases, with as many as 15 being related to radiotherapy injury to tissues surrounding the neoplasm, thus confirming this to be the most frequent cause for insurance claims. The other 11 causes are also reported. CONCLUSIONS: Now that the historical causes of error that led to incorrect radiotherapy treatment have been eliminated through strict adherence to protocols, risk management in radiotherapy identifies side effects as the main source of risk for patients and physicians. Data analysis confirms the need to implement risk management procedures in radiotherapy in which insurance claims (15/26 cases) are motivated by side effects of treatment.

[Liability claims in radiology: an 8-year follow-up and future projections]. / Denunce di responsabilità civile in radiologia. Otto anni di osservazione e proiezioni future.

AIM: The analysis of the liability claims filed by Italian radiologists over the past 8 years allows us to evaluate past trends and predict the future evolution of litigation in radiology. MATERIAL AND METHODS: The assurance claims of Italian radiologists over the 1993-2000 period were anonymously evaluated. A total number of 422 claims were classified according to the cause as due to: 1) missed diagnoses; 2) complications; 3) failure to order further radiological examinations; 4) iatrogenic lesions due to radiation therapy; 5) slip-and-fall injuries; 6) miscellaneous cases. The data were analysed using descriptive statistics and curve estimation, i.e. selection of the regression models which best fit the observed data. RESULTS: Claims showed a linear increase from 1993 to 2000; however exponential increase could not be ruled out. The incidence risk-rate of claims rose over 45 per thousand persons/year. Misdiagnosis represented the first and most important claim category (>60% of total). Missed bone and joint abnormalities accounted for the greatest percentage of cases (37.8%). Missed abnormalities on breast and chest radiographs were the following most common diagnostic errors (25.2% and 15.0%, respectively). Within this class of claims, missed malignant lesions of the breast showed the greatest increase in number. Claims alleging complications resulting from radiological examinations or procedures were 13% of all cases. These complications mostly occurred following administration of i.v. contrast medium, or due to interventional procedures, or barium edema. Slip-and-fall accounted for 6% of cases. A few cases (0.7%) resulted from failure of the radiologist to order further diagnostic examinations. Finally, in roughly 12% of all cases, the radiologists were named as one of multiple defendants, together with medical doctors or other clinicians, in cases of patient's death. CONCLUSIONS: The risk of being sued for Italian radiologists is now comparable to that radiologists in the United States. Strict adherence to radiological standards will probably not be sufficient to reduce the risk of being sued. Special legislative measures may be required to obviate litigation.

[Complaints against radiologists in Italy]. / Denunce contro i radiologi in Italia.

INTRODUCTION: Legal claims against radiologists are a relevant phenomenon also in our country and represent an increasing risk for a radiologist's professional activity. MATERIAL AND METHODS: We reviewed the 1993-1998 insurance claims against Italian radiologists. We found 259 claims subdivided by type into: 1) misdiagnosis; 2) complications of the examination; 3) missed referral for further examinations/treatment; 4) (non)ionizing radiation treatment; 5) slip-and-fall injuries; 6) miscellaneous cases. All claims were reviewed anonymously. RESULTS AND DISCUSSION: Most of the 259 malpractice claims were filed late after the event, which makes the actual incidence of the phenomenon difficult to evaluate. Nevertheless the incidence of malpractice claims can be estimated at 32 per thousand people a year, meaning that an Italian radiologist's risk of being sued by a patient at least once in his/her professional life exceeds 1. Alleged misdiagnosis was the most frequent claim category. Missed bone abnormalities of any type, including fractures, dislocations, malignant lesions and other nonspecific conditions accounted for 52.9% of cases. Missed abnormalities on breast and chest examinations accounted for 17.5% and 15.3%, respectively. Within this claim category, missed breast lesions exhibited the most increasing trend. Alleged complications from radiological examinations accounted for 20% of cases and mostly involved i.v. contrast agent administration, interventional procedures and barium enema. Slip-and-fall injuries, where the patients falls off the examination table, slips on the floor, bumps into a piece of equipment and so on, accounted for 7% of cases. Missed referral to further examinations accounted for 1.5% only. Finally, radiologists were frequently sued as one of many defendants, together with medical/surgical doctors, in case of patient's death, in 20% of all cases. CONCLUSIONS: Italian radiologists currently run the same risk of being sued for malpractice as their American colleagues. Strict compliance with radiological standards is recommended to try to decrease the risk and to obviate litigation.

Work-related musculoskeletal complaints in sonologists.

The prevalence of musculoskeletal complaints of the hand and wrist, and the neck and back, in physicians who operate sonography equipment was evaluated, and associations between these complaints and various work-related and personal variables were studied. A questionnaire survey was distributed among physician sonographers (sonologists) in Italy. The relationship between work habits and musculoskeletal complaints was analyzed by logistic regression models adjusted for gender, age, and duration of work with ultrasound. A total of 2041 physician sonographers completed the questionnaire. It was found that a large proportion of the subjects regularly had work-related complaints, such as neck and back pain (NBP) (18.5%) or hand and wrist cumulative trauma disorder (HWD) (5.3%). Roughly 80% of the sonographers were currently affected, or had been affected in the past, by one or more work-related symptoms. Various work-related factors appeared to be related to musculoskeletal syndromes. The average time spent for each examination was related both to NBP and HWD. Discomfort for transducer design was the best predictor of HWD, whereas a comfortable chair and correct position of the body protected from the onset of NBP. These results support the role of ergonomic factors in the pathogenesis of both NBP and HWD in sonographers.