| Abstract|| |
Background: Pathologists are indispensable to the practice of medicine. Awareness of health hazards among pathologists is a crucial aspect of today's time. Numerous occupational health risks are prevalent which are mostly ignored; for example, the association of microscope use for prolonged durations leading to the development of chronic pain syndromes has been acknowledged for nearly three decades, yet most pathologists are unaware about this hazard until after it transforms into a chronic health issue. The purpose of this study is to learn its prevalence in working pathologists, make them aware of the risks, discuss and encourage them to proactively integrate strategies which are preventive in nature into their daily routine lives. Objective: The aim of the study was to analyze the level of risk, knowledge, awareness and biosafety measures taken by the pathologists in their routine daily work life. Materials and Methods: The study was conducted in a developing country, Northern India, using a standard online 50-item questionnaire enquiring about routine practices. 450 participants were enrolled consisting of 360 pathologists and 90 residents of pathology. Results: Among the 450 enrolled study participants, 84.8% complained of musculoskeletal disorders (MSD), with the neck being the commonest location of pain. Furthermore, 74.8% reported visual refractive errors, among which myopia took the highest place. Work injuries were reported in 60% of participants. Intolerance reactions to chemicals especially formaldehyde was observed in 63.1%. Depression and burnout were reported in 42%. Conclusions: Although knowledge seems to be near adequate, there is a lack of implementation and a noticeable risk of health hazards namely musculoskeletal problems, injuries, visual disorders, and ergonomic issues in routine daily activities of pathologists.
Keywords: Hazards, occupational, pathologist, questionnaire
| Introduction|| |
Pathology is a critical area of medical science. It is the basis of all clinical medicine with around 70%–80% dependance by treating doctors on a broad array of lab results to devise treatment strategies. The importance of behind-the-curtain doctors—pathologists—who are the indirect patient care providers in an individual's life goes barely noticed as the world sees pathology as an easy, isolated, sit-alone-in-a-basement job. It is more than what the common perspective is. The average day of a pathologist revolves around sitting for long hours glued to the microscope that leads to musculoskeletal disorders commonly involving the back and neck.,,,,,, Exposure to contaminants, germs, chemicals, and injury remains another significant issue which is mostly overlooked., Chemicals like formaldehyde used in gross room procedures is a known irritant that causes a spectrum of problems, ranging from irritation to the eyes to even hematopoietic and lymphatic malignancies.
A study conducted by Fritzsche et al. was one of the earliest extensive studies in this regard in which the occupational health risks were evaluated in 163 pathologists in Switzerland. A few other studies were carried out in different parts of the Middle East, Iran and Pakistan. Many studies investigated only one or two occupational risk factors. This study is the first detailed extensive evaluation holding utmost importance especially in developing countries, considering the fact that there are limited studies highlighting the importance of awareness, knowledge, safety and precautions to be taken as a pathologist. Prevention requires a thorough knowledge of risks and understanding the measures to be taken. It is crucial to create awareness and do a routine timely assessment of biosafety in the workplace environment.
| Material and Methods|| |
The study was primarily based on a 50-item questionnaire. All participants were first provided with a consent form stating use of their data and responses for research. Upon successful completion, the questionnaire was provided to them.
The study comprised of pathologists and residents of pathology working in North India. An email was individually sent to them with enclosed links to a consent form and the questionnaire. An exclusion criterion was set in which pathologists working part-time or in a non-laboratory setting at the time the study were excluded. Participants on drugs for chronic ailments were also excluded from the study negating the risk of bias.
The study instrument was a written questionnaire containing basic questions on demographic information, total number of working hours on the microscope, respiratory complaints, routine lab practices, occupational health and hazards, the work environment, unsafe work practices, use of PPE, specimen handling, and disposal and confrontation attitudes for occupational hazards. The participants were expected to answer in depth about their personal experience with hazards like musculoskeletal disorders, psychological effects, exposure to laboratory chemicals and contaminants, visual disorders, hypersensitivity reactions, and allergies.
Questionnaires were re-evaluated and used as the validity and reliability were confirmed, and then was transferred to an SPSS file and analyzed using SPSS version 20.0. P value of less than 0.05 was considered significant.
| Results|| |
In this study, 450 participants were enrolled consisting of 360 pathologists and 90 residents of pathology. 260 participants were women (57.8%) and 190 were men (42.2%). It was estimated that 275 participants (61.1%) were younger than 45 years. Almost 75% of the participants (n = 337) worked more than 50 hours per week, and 113 (25%) had working hours less than 50 hours per week. Working on a microscope was reported by 428 (95.1%) participants. The commonly encountered problems were [Figure 1]:
Musculoskeletal disorders (MSD)
The study highlighted those 382 participants (84.8%) who complained of musculoskeletal pain that developed after they starting to use the microscope. Neck pain, experienced by 396 participants (88%), was the commonest and the most significant reported pain location followed by shoulder (08%) and back pain (04%). Strikingly higher rates of musculoskeletal disorders (MSD) were reported amongst young pathologists when compared to the older ones (P = 0.008) due to lack of information about correct posture and ergonomics to be followed. Duration of use of microscope and working hours per week was found to be directly proportional to the MSD. Doctors who worked on the microscope for more than five hours per day experienced higher rates of MSD (P = 0.02). No significant difference was observed amongst men and women.
A total of 337 participants (74.8%) reported visual fatigue, conjunctivitis, and new onset refractive errors such as myopia; Myopia was seen most commonly in 39% participants. 113 previously ametropic pathologists (25%) experienced an aggravation in refractive error averaging around 1.2 D. Refractive errors were found to be more prevalent amongst women (P = 0.034).
Eye fatigue was significantly associated with microscope usage for more than five hours per day (P = 0.043), However the duration of microscope use was not significantly associated with refractive errors (P = 0.087).
Injuries were reported in 270 participants (60%) amongst which the most common was cutting injury (52%), at least once while handling tissue (surgical specimens and autopsy) in the gross room. Only 30% used double gloves or cut-resistant gloves. Mucous membrane splashes or blood spill remained the second most common (35%) injury. Work injuries were significantly more prevalent among the resident pathologists compared with consultants (P = 0.023). The use of first aid post injury was taken by 70% of the respondents. However, post exposure event reporting was done by only 45%.
Reactions to formalin including allergies such as mucosal irritation, skin irritation, and rashes were experienced by 284 pathologists (63.1%). Residents were significantly observed to be more prone to intolerance reactions to formaldehyde (P = 0.027). However, no significant difference was noticed between men and women (P = 0.13).
Depression and burnout were also experienced by 42% of the study participants that developed at some point of time in their career. This was observed to be significantly more amongst men than women.
Five individuals had a history of malignancy (1.1%): one case of lymphoma, one thyroid cancer, one renal cell carcinoma of kidney, and two unknown malignancies. This was found to be unrelated to formaldehyde.
89% were found to be immunized with Hepatitis B vaccination and 71% with BCG vaccine.
Knowledge and implementation
On the basis of the response received regarding awareness, knowledge, and biosafety precaution questions, 270 participants (60%) were found to be aware of universal work precautions, and proper knowledge of ergonomics was seen in 30%. 234 (52%) were found to leave the laboratory without following proper handwash rule after finishing duty. Eight individuals had severe infections such as tuberculosis and hepatitis C earlier in life, and 45 (10%) of them had biosafety training earlier. 135 respondents (30%) were aware about the usefulness of taking short breaks and frequently incorporated it into their work life. Numerous ill practices were unknowingly followed in the laboratory, compromising on health and safety in the workplace, like mouth pipetting of reagents (35%) and storage of food and drinks in the same refrigerator as the reagents (68%). Use of lab coat or personal protective equipment was seen in only 243 respondents (54%) [Table 1] and [Table 2].
| Discussion|| |
This study highlighted how working in the field of pathology has short- as well as long-term consequences. A major chunk of the problems can be ameliorated solely by creating awareness amongst pathologists. Timely reminders and interventions should be scheduled, and it should be emphasized over and over to pathologists to seek evaluation and treatment for work-related issues, even if the symptoms are mild. During the research, it was found that a high frequency of occupational health issues were attributed to musculoskeletal disorders followed by visual acuity errors, accidental injuries, and chemical intolerance. The average day of a pathologist comprises of sitting glued to the microscope or computer for several hours. As time passed, we have seen an ascending trend in the number of samples and specimens that require examination by the microscope. The microscope to the pathologist is what a stethoscope is to the physician. It is the main and the most basic equipment used in laboratories. Although the microscope serves a great deal of advantages, the human body and eyes cannot sustain long working hours on it.
Musculoskeletal pain occupies the top most position of work-related problems faced by pathologists, present in 382 participants (84.8%). There was no relation to gender, but the frequency was surprisingly higher amongst younger pathologists, which ruled out the common belief that MSDs are age related. A high degree of knowledge and preventive strategies should always be maintained starting at a younger age. Our findings were in concordance with those of Fritzche et al. and Kadivar et al. Timely worksite evaluation by an experienced person having expertise in ergonomics should be done. Physical therapy for affected individuals should be encouraged to improve posture, flexibility and body endurance. As prevention is the best approach for at-risk pathologists, it is important to realize the importance of having workstations optimized and adjusted according to the users' requirements. Microscopes should have adjustable eyepieces so that one can look directly into the eyepiece. Care should be given to maintaining a neutral spine posture. The microscope should be placed towards the edge of the desk to constraint the user to sit upright without rounding the neck and shoulders. Ergonomically designed chairs should be used with arm rests, upper and lower back support, adjustable height and seat angle.
Pathologists should limit the use of the microscope to a maximum of five hours per day. Small regular breaks should be taken instead of uninterrupted microscope hours. Brief stretching exercises should be incorporated during these breaks.
Visual disturbances (74.8%) were another health issue showing more prevalence amongst pathologists compared to other health professionals in the study; the frequency of refractive errors was reported in 39%, mostly myopia. On the other hand, 25% of our participants admitted that their refractive error was exacerbated by their working hours. Although this finding is parallel to the study conducted in Switzerland by Fritzsche et al., we cannot conclusively say that work is the sole contributor, as time and the process of aging also play a vital role in visual deterioration.
Acute injuries at the workplace remain to be inevitable. In our study, 60% of the participants had at least one incidence of acute injury. Cutting injury was the most common type of injury. Lack of awareness towards the advantages and usage of cut-resistant gloves was observed. This was in line with the study by Fritzsche et al. and Kadivar et al. Residents experienced a significantly higher prevalence of cutting injury than the specialists had, which is quite comparable to the findings in the study by Fritzsche et al. This can be justified with the fact that young new residents lack experience and are not familiar with protective measures. Here, the role of cut-resistant gloves comes into play. Educational programs and training should be suggested to inform them about the safety measures. Regarding washing hands, the study showed that only 48% washed their hands with plain water before leaving the lab, and only 35% used soap plus antiseptic for handwashing. A study conducted in Saudi Arabia showed the 61% of their respondents washed their hands properly, while the study from Karachi revealed that 100% of respondents washed hands properly.
Formaldehyde remains the most commonly used fixator in pathology. Intolerance reactions like skin and mucosal irritation, allergies and eye discomfort were the most commonly encountered ill effects occurring in 63.1% of the participants. These were observed more in residents. The occurrence rate was higher compared to the study by Fritzsche et al. but was comparable to Kadivar et al. The primary difference stems from the standard of laboratories and availability of proper ventilation.
89% of our participants reported immunization against hepatitis B. This rate is less compared to that reported in Switzerland, thus warranting improvement. However, due to the importance of immunization among health care professionals, we recommend screening programs to increase the vaccination coverage to 100% in this high-risk group. According to the study done in Switzerland, 93.9% were immunized with HBV vaccine and 78.5% were immunized with BCG vaccine whereas in our study population, 89% were immunized against HBV and 71% were immunized with BCG vaccine which is lesser than the former.
Common medical conditions in our study population included depression and burnout (42%) that had slightly higher frequencies compared to the study by Fritzsche et al. Burnouts is a loss of sense of personal accomplishment, depersonalization, and emotional exhaustion. Every pathologist has experienced it at some point in their career. Measures should, however, be taken to manage the stress of the field. The primary driving force is respect. As a purely diagnostic specialty, pathologists mostly depend on their fellow clinicians for access to the patients. In return, most of the time, the treating doctors don't see them as colleagues but as service providers, causing residents to chafe under this erosion of image and respect. Feelings of dependence and subservience are enough to cause burnouts in pathologists, making them question their worth as doctors. The second driving force for the same is the isolated environment in which a pathologist works.
Only five participants were encountered to have malignancy, but it did not seem to be associated with exposure to formalin.
Regarding any formal training, only 45 individuals, corresponding to 10% of the study population, received biosafety training. 60% of respondents in a study in Karachi, claimed that they had received formal biosafety training whereas another study that included pathology personnel from all the four provinces claimed that only 15.8% of the study population received formal biosafety training. This was an aspect which was least paid attention to during the early phases of pathologists. Educational programs and training should be incorporated as early as during the orientation sessions when a fresh pathologist joins.
| Conclusion|| |
As pathologists, we have specialized skills unique to other fields of medicine. The skill that makes other doctors and patients rely on us for the final diagnosis. However, being behind the scenes has its disadvantages such as occupational health hazards, physical and mental problems being most common. In this study, we tried to bring those issues to light and emphasized on the need to promote awareness, knowledge, and protective and preventive measures at any point of their career. Also, the study proved that investing in improving the personal well-being of the pathologist is crucial and the need of the hour, and it can enhance their output and health. The strength of this study includes being the only detailed study on occupational health in a developing country.
The following are the recommendations that are suggested for the working pathologists, concluded from this study:
- Minibreaks of five to ten minutes every hour should be encouraged.
- Proactive integration of posture correction while walking and during routine microscope time should be done in daily life.
- The laboratory accidents should be documented, proper safety measures should be followed vigilantly along with due importance given to up-to-date immunizations.
- There should be institutional biosafety training programs to create awareness of basic safety principles, equipment, storage, disposal and transport of biological material. Written SOPs should be made for the laboratories.
- A team having expertise should be made to examine the laboratory design, safety, ergonomics, workstation layout, and ventilation at timely intervals to safeguard the health of the working pathologists.
- Burnout is an issue which attracts very little coverage. Healthier systems that recognize burnouts should be built and addressed.
- Pathology departments and labs should be given a prominent position in the hospital so that patients and professionals can come to talk and discuss the results.
The author sincerely thanks all of the pathologists and residents who took part in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kadivar M, Mokamelkhah EK, Shams ZH. Work-related hazards among pathologists and residents of pathology: Results of a cross-sectional study in Iran. Iran J Pathol 2021;16:274-83.
George E. Occupational hazard for pathologists: Microscope use and musculoskeletal disorders. Am J Clin Pathol 2010;133:543-8.
Jain G, Shetty P. Occupational concerns associated with regular use of microscope. Int J Occup Med Environ Health 2014;27:591-8.
Haile EL, Taye B, Hussen F. Ergonomic workstations and work-related musculoskeletal disorders in the clinical laboratory. Lab Med 2012;43:e11-9.
Agrawal PR, Maiya AG, Kamath V, Kamath A. Work related musculoskeletal disorders among medical laboratory professionals: A narrative review. Int J Res Med Sci 2014;2:1262-6.
Waisman J, George E. More on occupational hazards for pathologists. Am J Clin Pathol 2010;134:850.
Lorusso A, Bruno S, Caputo F, L'Abbate N. Risk factors for musculoskeletal complaints among microscope workers. G Ital Med Lav Ergon 2007;29:932-7.
Hall A, Harrington JM, Aw TC. Mortality study of British pathologists. Am J Ind Med 1991;20:83-9.
Kubiczek P, Langona M, Mellen PF. Occupational injuries in a pathology residency program. Arch Pathol Lab Med 2006;130:146-7.
Collins JJ, Esmen NA, Hall TA. A review and meta-analysis of formaldehyde exposure and pancreatic cancer. Am J Ind Med 2001;39:336-45.
Fritzsche FR, Ramach C, Soldini D, Caduff R, Tinguely M, Cassoly E, et al
. Occupational health risks of pathologists-results from a nationwide online questionnaire in Switzerland. BMC Public Health 2012;12:1054.
Sillanpaa J, Nyberg M, Laippala P. A new table for work with a microscope, a solution to ergonomic problems. Appl Ergon 2003;34:621-8.
Akhter J, Johani S, Hammad L, Zahrani K. Laboratory work practices and occupational hazards among laboratory health care workers: A health and safety survey. J Pharm Biomed Sci 2011;9:1-4.
Khan S, Zehra F, Maqsood N, Zahid M, Ahmed B. Biosafety practices in different clinical laboratories in Karachi, Pakistan. J Dow Univ Health Sci 2014;8:94-7.
Glasheen JJ, Misky GJ, Reid MB, Harrison RA, Sharpe B, Auerbach A. Career satisfaction and burnout in academic hospital medicine. Arch Intern Med 2011;171:782-5.
Nasim S, Shahid A, Mustufa MA, Arain GM, Ali G, Taseer IU, et al
. Biosafety perspective of clinical laboratory workers: A profile of Pakistan. J Infect Dev Ctries 2012;6:611-9.
Department of Pathology, JNMCH, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]