Surgical Ergonomics - Current state and future directions
TimeTuesday, April 132:00pm - 3:00pm EDT
DescriptionSurgical work is characterized by high demand across physical, mental and psychosocial dimensions. This can lead to impaired surgical well-being, leading to higher surgeon disability, decreased quality of life, reduced career longevity, reduced patient safety, reduced quality of surgical care and overall reduced functioning of the surgical healthcare system, which incurs a great patient and societal cost. This panel will discuss prevalence and drivers as well as an educational intervention (Dr. Lal), show how they occur and what non-educational interventions have worked (or not) showing a large gap that needs to be filled (Dr. Hallbeck). We will explore how worker’s comp is at the end of the line and too late for surgeons (Dr. Corwin) . We will then wrap up with how the surgeon pain can influence patient safety. Ending with a framework for surgeon wellness (Dr. Chrouser).
Work-related injury is common among surgeons, with many reporting symptoms of musculoskeletal pain as a result of their surgical practice. They can also develop other symptoms such as fatigue, numbness and stiffness and the neck and back appear to me most commonly affected. These symptoms affect surgeons across all specialties, however, endoscopic/laparoscopic surgeons have the highest rates. Development of musculoskeletal pain and other symptoms while operating is thought to be due to long periods of standing, sustained adverse postures (e.g., neck flexion, nonneutral positions), repetitive movements, limited recovery time, and use of non-ergonomic equipment, including instruments, loupes, headlights, and lead aprons. Use of electronic medical records can also contribute to posture issues and pain outside of the operating room. The strain brought about by poor work-place ergonomics is likely exacerbated by the surgical culture and attitude among surgeons, with many surgeons prioritizing the health and safety of their patients while neglecting their own comfort and well-being. Work-related strain can impact a surgeon’s physical and mental health, as well as their quality of life and career longevity. Further, studies have demonstrated that ergonomic issues associated with operating can impact the future of surgical specialties by reducing student interest in pursuing surgical careers.
Recently, there has been increased interest in developing and implementing strategies to reduce work-related injuries among surgeons, as Dr. Hallbeck will discuss. Despite these efforts, education on the recommendations made in the field of surgical ergonomics is lacking in surgical programs. To date, few surgical residencies incorporate education on surgical ergonomics into their regular curriculum. In fact, a study found that only 1.5% of program directors reported having some type of formal surgical ergonomics education as a part of their residency curriculum. This is despite data reporting that symptoms develop early on in training.
At Dr. Lal’s institution, we recently investigated the feasibility and impact of adding formal ergonomic education sessions to the resident curriculum . A survey was distributed to 42 residents with questions regarding demographics, surgical factors, prevalence of musculoskeletal (MSK) symptoms, and awareness of ergonomic recommendations. The residents then received two lectures on ergonomics in surgery. A follow up survey was distributed to evaluate the impact of the lectures. Of the residents who completed the pre- survey, 91% reported musculoskeletal symptoms attributed to their training. All those who completed the post-survey reported increased awareness of their own habits while operating and improved understanding of methods to prevent/treat work-related injuries. All residents recommended incorporating the lectures as an adjunct to their regular curriculum. Our study showed that residency is an opportune time to educate on ergonomics and may prevent future injuries in surgeons.
Initially, HF/E awareness needs to be raised for the surgeon and surgical teams via education which Dr. Lal discussed. Then appropriate interventions must be co-created and tested. These may be as simple as floor mats or supportive shoes. Fixtures for retraction or arm rests for longer surgeries where a surgeon or team member is required to extend their arms in static postures for long durations would be another option. Changes in instrumentation have been long overdue, especially for small-handed surgeons. Anecdotally, we see that many surgeons who are at larger institutions are moving from open/laparoscopic surgeries toward robot-assisted surgeries to, in part, reduce their physical load.
Dr. Hallbeck’s team is currently pilot testing passive low back and neck exoskeletons in the vascular operating room. Initial results are showing reduced trunk and neck angles; which may be due to increased awareness, as well as the impact from the exoskeletons.
Exercise/Stretching interventions such as microbreaks have fared better than instrumentation changes, largely due to low cost and demonstration that the surgical duration isn’t lengthened with their use. In a similar way, targeted exercise outside the OR has been shown to help with surgical pain. However this is not a systems solution.
Surgeons often do not recognize, or fully accept that the pain and injury they are experiencing arises from the work they love. A culture of long hours and high self-expectations have inoculated most surgeons with a reluctance to accept personal limitations and an even greater reticence to make one’s limitations “public”. There is limited published data in the scientific literature regarding worker compensation claims and outcomes by surgeons. We expect that most surgeons know very little about the workers’ compensation system, and that fewer have actually submitted a workers’ compensation claim.
The worker’s compensation (WC) system dates back to the late European “sickness and accident” laws of 1800’s. In the early 1900’s the first workers’ compensation laws took root in the US, with Wisconsin as the leader in 1911.
First, workers’ compensation is a no-fault system and benefits are limited by statute – administered by state agency. It is the exclusive remedy for a work-related injury. A person who is injured at work does not have to prove that his/her injury was caused by the negligence of the employer. Second, the amount of compensation that an injured worker will receive is calculated by a formula based on (a) the worker’s earnings and (b) the nature and severity of the injury. Third, injured workers are not required to go to court, and an injured worker is not required to be represented by an attorney, although it may be advisable. Employers and insurance companies will almost always be represented by an attorney. Fourth, an injured worker does not have the right to sue his/her employer for a work-related injury, but instead must pursue the claim through the workers’ compensation system. Finally, this is a state directed system, each state with its own nuances and limitations. Hence, a judgment in Iowa may be very different than a judgement next door in Illinois.
There are important concepts for one to understand if one is to submit a claim for what one believes, or suspects, is a work-related injury or illness. First, “causation” must be established as accurately as possible. Second, it is crucial to understand the concept of “work restrictions”. This is a particularly difficult reality of treatment for work-related injuries, especially for surgeons who often find it difficult to comply with a treatment regimen that includes restrictions. “Maximal medical improvement” (MMI) occurs when condition is well stabilized and unlikely to change substantially in the next year with or without medical treatment.” Reaching MMI while still experiencing symptoms can be very problematic for active surgeons who are nor ready to otherwise ready to stop operating. Embodies in all of these foundational concepts are issues of personal fulfillment, employability, and personal financial outcomes. On an institutional level there are economic ramifications.