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The evidence has been accumulating for decades: Practicing surgery can exact a toll on surgeons’ physical well-being in ways that can shorten careers and contribute to professional dissatisfaction.
“Ergonomists have described the surgeon’s work environment and working conditions as equal to, if not at times harsher than, those of certain industrial workers,” wrote Sherise Epstein, MPH, and the coauthors of the systematic review and meta-analysis of studies addressing the issue. Ms. Epstein, currently a 4th-year medical student at the University of California, San Diego, and her team found a high prevalence of work-related musculoskeletal disorders and pain among surgeons and interventionalists, with pooled prevalence estimates for pain among these physicians ranging from 35% to 60% of all respondents. Cervical spine disease, rotator cuff pathology, and degenerative lumbar spine disease were each reported by nearly one in five respondents in the pooled analyses, with increasing prevalence over the duration of the study period (JAMA Surg. 2017 Dec 27. doi:10.1001/jamasurg.2017.49).
These findings, called “worrisome” by the study’s authors, come at a time when the demand for surgeons and interventionalists is expected soon to outstrip supply, and point to a major stressor for a profession already plagued by high rates of burnout and depression.
The results of the study are in line with previous work that finds a high – and increasing – rate of pain and disability among at-risk physicians, who endure long work hours, awkward positioning, and few opportunities for breaks.
The study also suggested a possible linkage between work-related pain and other factors, such as burnout and depression, that lead to attrition in the surgical profession.
Adrian Park, MD, FACS, a general surgeon who has long studied the issue of work-related musculoskeletal disorders (MSDs) among surgeons and interventionalists, was not surprised by the study’s findings. “This just goes to further the narrative, which is a consistent one: These aren’t just sporadic instances of individual surgeons having a tough time; this is an increasingly broadly recognized problem. ... These are the consequences of surgeons simply getting up and going to work each week,” Dr. Park said in an interview.
To take a long view of the published data on work-related injury and pain for at-risk physicians, Ms. Epstein and her collaborators identified 126 articles reporting physician work-related MSDs that met quality standards; the studies spanned 1974 to 2016, and 23 countries were represented.
A total of 21 articles were eventually included in the meta-analysis, which included responses from 5,828 physicians. Most of the respondents were male (78.5%), with a mean age of 46 years and a mean 12.8 years in practice. The mean number of hours spent in procedures per week was 14.4.
Sixteen cross-sectional studies included in the meta-analysis examined injury prevalence, with 14 studies eventually meeting eligibility criteria for quantitative synthesis. A total of 4,245 physicians were included in this portion of the analysis; 1,232 were orthopedic surgeons, 1,118 were interventional cardiologists, and 582 were general surgeons (a variety of other subspecialties made up the remainder).
The career prevalence of degenerative lumbar spine disease was estimated at 19%, with prevalence increasing over time in a series of surveys of interventional cardiologists, said Ms. Epstein and her colleagues. Among this group, the prevalence climbed from 6.5% in 1997 to 24.7% in 2015, an increase in prevalence of over 18%, they said. The investigators’ estimate of lumbar spine disease prevalence from their own data also showed an increase, to 21%, for studies published within the past decade.
Rotator cuff pathology during the study period was estimated at 18% overall, and carpal tunnel syndrome at 9% overall; carpal tunnel syndrome also appears to be increasing in prevalence, estimated at 12% within the last decade.
Musculoskeletal pain that was judged to be work related was common, as reported in 18 cross-sectional studies. Taken together, the studies used a total of five validated tools that measured both pain prevalence and related disability. Twelve of the studies met criteria for inclusion in the quantitative synthesis.
Neck, back, and shoulder pain were all common in this group of surgeons and interventionalists. Neck pain had a 60% estimated 12-month prevalence, and shoulder pain was almost as common, with a 52% prevalence; back pain was reported for about half (49%) of respondents.
Just 10 of the included studies addressed disability burden, said Ms. Epstein and her colleagues. Overall, 12% of physicians responding in this subset of studies reported that they required work modification, leave of absence, or early retirement because of work-related MSDs.
In a separate arm of the analysis, Ms. Epstein and her collaborators looked at studies that discussed ergonomic assessments and interventions, using a qualitative approach. A total of 101 studies, 50 of them in the United States, were included. None of the studies, they said, “included long-term surveillance for work-related MSDs”; rather, they focused on short-term outcomes and, in some cases, on real-time electromyographic data.
Of the 101 studies looking at ergonomics, about a third (n = 38) looked primarily at ergonomically designed devices or technology, while another third (n = 37) focused on educational or behavioral interventions and modifications. These were the studies included in the investigators’ analysis.
A lack of awareness of ergonomic recommendations on the part of the surgeons themselves was identified in several studies. Several specialties, publishing in a total of eight countries, have put forward “at least one article describing a need for ergonomics education during medical training.” And, said the investigators, “A few studies have found that ergonomics education during medical training appears feasible, accepted, and effective at changing behaviors and reducing symptoms.”
In addition to the usual limitations inherent to the meta-analysis research design (selection bias, self-reported data, small samples of individual studies), the study was limited by the elusive nature of the topic. Work-related pain and disability among surgeons remains underreported and underestimated, according to both Dr. Park and the study investigators. Further research is needed, and the investigators wrote: “Ultimately, this work should be integrated with research on preventing surgeon burnout and attrition given shared risk factors.”
Micro breaks can help
What’s the solution? Dr. Park says that some fixes are low tech, and can be put in place immediately. He and his team implemented a series of brief breaks, taken every half hour during a procedure, that they dubbed “targeted stretching micro breaks.” These are 45- to 50-second breaks during which a series of exercise physiologist–designed brief stretches are undertaken that do not require breaking scrub.
In a study of 66 surgeons and operating room staff, Dr. Park, chair of the department of surgery at Anne Arundel Medical Center, Annapolis, Md., and his collaborators found that surgeons reported less pain and fatigue, and improved mental focus, when they took micro breaks during a procedure. When surgeons took micro breaks, operative time was no longer than when they didn’t take the breaks (Ann Surg. 2017 Feb;265[2]:340-6).
“We do this all the time in our operating room now,” said Dr. Park. “And it makes a difference in terms of pain, in terms of alertness, in terms of stamina. And it costs nothing.”
Major redesign of tools and workspace
Other targets for technological improvement include offering better-designed handles for laparoscopic instruments. “We’ve had one size fits all forever. Why has it taken us so long to recognize that there’s not one size of surgical hand?” asked Dr. Park. He made the point that the influx of women – whose hands are smaller on average than men’s – into the surgical professions makes this a particularly pressing issue.
“The high-tech piece is going to be a better understanding of the operative work flow,” said Dr. Park, calling for “a meaningful revisiting of the surgeon-device interface and the surgeon-patient interface.”
A fundamental redesign of the operating room will eventually be in order, he said, contrasting the surgeon’s environments with that of an airline pilot. In the cockpit, the pilot sees a “heads-up” display of a limited amount of data, with an eye to controlling the cognitive workload for the operator. By contrast, said Dr. Park, in the OR, there are “lights flashing, and things pinging,” and pieces of equipment don’t “talk” to each other, presenting sometimes overwhelming sensory input that just potentiates the stress of the environment. Operating room design, he said, should move toward an ergonomically improved and stimulus-controlled environment.
As the leader of the surgical team, and as a physician whose foremost concern is the patient on the table, the surgeon may inadvertently have fallen into a role where his or her well-being is neglected.
Dr. Park suggested that, in the surgical profession, “it has never felt safe or appropriate to talk about ourselves.” But for the good of the profession, and ultimately for patient care, “this has to change.”
Ms. Epstein and her coauthors reported no conflicts of interest. .
We rarely think of surgeons as athletes and certainly we sometimes don’t look like athletes, but surgery is a performance sport that includes strength and grace. Many surgeons are also very active outside the OR. So, not only OR activity but all the other activities are stacked upon our bodies. Posture, strength training, and ergonomics need to be part of our training just as it would for a pitcher for the Kansas City Royals. You wouldn’t expect the pitcher’s arm to last long without coaching and training physically. That player’s career would be shortened. Why would we expect surgeons to be different? Our game is 90% mental, but the other half is physical (with respect to Yogi Berra).
We rarely think of surgeons as athletes and certainly we sometimes don’t look like athletes, but surgery is a performance sport that includes strength and grace. Many surgeons are also very active outside the OR. So, not only OR activity but all the other activities are stacked upon our bodies. Posture, strength training, and ergonomics need to be part of our training just as it would for a pitcher for the Kansas City Royals. You wouldn’t expect the pitcher’s arm to last long without coaching and training physically. That player’s career would be shortened. Why would we expect surgeons to be different? Our game is 90% mental, but the other half is physical (with respect to Yogi Berra).
We rarely think of surgeons as athletes and certainly we sometimes don’t look like athletes, but surgery is a performance sport that includes strength and grace. Many surgeons are also very active outside the OR. So, not only OR activity but all the other activities are stacked upon our bodies. Posture, strength training, and ergonomics need to be part of our training just as it would for a pitcher for the Kansas City Royals. You wouldn’t expect the pitcher’s arm to last long without coaching and training physically. That player’s career would be shortened. Why would we expect surgeons to be different? Our game is 90% mental, but the other half is physical (with respect to Yogi Berra).
The evidence has been accumulating for decades: Practicing surgery can exact a toll on surgeons’ physical well-being in ways that can shorten careers and contribute to professional dissatisfaction.
“Ergonomists have described the surgeon’s work environment and working conditions as equal to, if not at times harsher than, those of certain industrial workers,” wrote Sherise Epstein, MPH, and the coauthors of the systematic review and meta-analysis of studies addressing the issue. Ms. Epstein, currently a 4th-year medical student at the University of California, San Diego, and her team found a high prevalence of work-related musculoskeletal disorders and pain among surgeons and interventionalists, with pooled prevalence estimates for pain among these physicians ranging from 35% to 60% of all respondents. Cervical spine disease, rotator cuff pathology, and degenerative lumbar spine disease were each reported by nearly one in five respondents in the pooled analyses, with increasing prevalence over the duration of the study period (JAMA Surg. 2017 Dec 27. doi:10.1001/jamasurg.2017.49).
These findings, called “worrisome” by the study’s authors, come at a time when the demand for surgeons and interventionalists is expected soon to outstrip supply, and point to a major stressor for a profession already plagued by high rates of burnout and depression.
The results of the study are in line with previous work that finds a high – and increasing – rate of pain and disability among at-risk physicians, who endure long work hours, awkward positioning, and few opportunities for breaks.
The study also suggested a possible linkage between work-related pain and other factors, such as burnout and depression, that lead to attrition in the surgical profession.
Adrian Park, MD, FACS, a general surgeon who has long studied the issue of work-related musculoskeletal disorders (MSDs) among surgeons and interventionalists, was not surprised by the study’s findings. “This just goes to further the narrative, which is a consistent one: These aren’t just sporadic instances of individual surgeons having a tough time; this is an increasingly broadly recognized problem. ... These are the consequences of surgeons simply getting up and going to work each week,” Dr. Park said in an interview.
To take a long view of the published data on work-related injury and pain for at-risk physicians, Ms. Epstein and her collaborators identified 126 articles reporting physician work-related MSDs that met quality standards; the studies spanned 1974 to 2016, and 23 countries were represented.
A total of 21 articles were eventually included in the meta-analysis, which included responses from 5,828 physicians. Most of the respondents were male (78.5%), with a mean age of 46 years and a mean 12.8 years in practice. The mean number of hours spent in procedures per week was 14.4.
Sixteen cross-sectional studies included in the meta-analysis examined injury prevalence, with 14 studies eventually meeting eligibility criteria for quantitative synthesis. A total of 4,245 physicians were included in this portion of the analysis; 1,232 were orthopedic surgeons, 1,118 were interventional cardiologists, and 582 were general surgeons (a variety of other subspecialties made up the remainder).
The career prevalence of degenerative lumbar spine disease was estimated at 19%, with prevalence increasing over time in a series of surveys of interventional cardiologists, said Ms. Epstein and her colleagues. Among this group, the prevalence climbed from 6.5% in 1997 to 24.7% in 2015, an increase in prevalence of over 18%, they said. The investigators’ estimate of lumbar spine disease prevalence from their own data also showed an increase, to 21%, for studies published within the past decade.
Rotator cuff pathology during the study period was estimated at 18% overall, and carpal tunnel syndrome at 9% overall; carpal tunnel syndrome also appears to be increasing in prevalence, estimated at 12% within the last decade.
Musculoskeletal pain that was judged to be work related was common, as reported in 18 cross-sectional studies. Taken together, the studies used a total of five validated tools that measured both pain prevalence and related disability. Twelve of the studies met criteria for inclusion in the quantitative synthesis.
Neck, back, and shoulder pain were all common in this group of surgeons and interventionalists. Neck pain had a 60% estimated 12-month prevalence, and shoulder pain was almost as common, with a 52% prevalence; back pain was reported for about half (49%) of respondents.
Just 10 of the included studies addressed disability burden, said Ms. Epstein and her colleagues. Overall, 12% of physicians responding in this subset of studies reported that they required work modification, leave of absence, or early retirement because of work-related MSDs.
In a separate arm of the analysis, Ms. Epstein and her collaborators looked at studies that discussed ergonomic assessments and interventions, using a qualitative approach. A total of 101 studies, 50 of them in the United States, were included. None of the studies, they said, “included long-term surveillance for work-related MSDs”; rather, they focused on short-term outcomes and, in some cases, on real-time electromyographic data.
Of the 101 studies looking at ergonomics, about a third (n = 38) looked primarily at ergonomically designed devices or technology, while another third (n = 37) focused on educational or behavioral interventions and modifications. These were the studies included in the investigators’ analysis.
A lack of awareness of ergonomic recommendations on the part of the surgeons themselves was identified in several studies. Several specialties, publishing in a total of eight countries, have put forward “at least one article describing a need for ergonomics education during medical training.” And, said the investigators, “A few studies have found that ergonomics education during medical training appears feasible, accepted, and effective at changing behaviors and reducing symptoms.”
In addition to the usual limitations inherent to the meta-analysis research design (selection bias, self-reported data, small samples of individual studies), the study was limited by the elusive nature of the topic. Work-related pain and disability among surgeons remains underreported and underestimated, according to both Dr. Park and the study investigators. Further research is needed, and the investigators wrote: “Ultimately, this work should be integrated with research on preventing surgeon burnout and attrition given shared risk factors.”
Micro breaks can help
What’s the solution? Dr. Park says that some fixes are low tech, and can be put in place immediately. He and his team implemented a series of brief breaks, taken every half hour during a procedure, that they dubbed “targeted stretching micro breaks.” These are 45- to 50-second breaks during which a series of exercise physiologist–designed brief stretches are undertaken that do not require breaking scrub.
In a study of 66 surgeons and operating room staff, Dr. Park, chair of the department of surgery at Anne Arundel Medical Center, Annapolis, Md., and his collaborators found that surgeons reported less pain and fatigue, and improved mental focus, when they took micro breaks during a procedure. When surgeons took micro breaks, operative time was no longer than when they didn’t take the breaks (Ann Surg. 2017 Feb;265[2]:340-6).
“We do this all the time in our operating room now,” said Dr. Park. “And it makes a difference in terms of pain, in terms of alertness, in terms of stamina. And it costs nothing.”
Major redesign of tools and workspace
Other targets for technological improvement include offering better-designed handles for laparoscopic instruments. “We’ve had one size fits all forever. Why has it taken us so long to recognize that there’s not one size of surgical hand?” asked Dr. Park. He made the point that the influx of women – whose hands are smaller on average than men’s – into the surgical professions makes this a particularly pressing issue.
“The high-tech piece is going to be a better understanding of the operative work flow,” said Dr. Park, calling for “a meaningful revisiting of the surgeon-device interface and the surgeon-patient interface.”
A fundamental redesign of the operating room will eventually be in order, he said, contrasting the surgeon’s environments with that of an airline pilot. In the cockpit, the pilot sees a “heads-up” display of a limited amount of data, with an eye to controlling the cognitive workload for the operator. By contrast, said Dr. Park, in the OR, there are “lights flashing, and things pinging,” and pieces of equipment don’t “talk” to each other, presenting sometimes overwhelming sensory input that just potentiates the stress of the environment. Operating room design, he said, should move toward an ergonomically improved and stimulus-controlled environment.
As the leader of the surgical team, and as a physician whose foremost concern is the patient on the table, the surgeon may inadvertently have fallen into a role where his or her well-being is neglected.
Dr. Park suggested that, in the surgical profession, “it has never felt safe or appropriate to talk about ourselves.” But for the good of the profession, and ultimately for patient care, “this has to change.”
Ms. Epstein and her coauthors reported no conflicts of interest. .
The evidence has been accumulating for decades: Practicing surgery can exact a toll on surgeons’ physical well-being in ways that can shorten careers and contribute to professional dissatisfaction.
“Ergonomists have described the surgeon’s work environment and working conditions as equal to, if not at times harsher than, those of certain industrial workers,” wrote Sherise Epstein, MPH, and the coauthors of the systematic review and meta-analysis of studies addressing the issue. Ms. Epstein, currently a 4th-year medical student at the University of California, San Diego, and her team found a high prevalence of work-related musculoskeletal disorders and pain among surgeons and interventionalists, with pooled prevalence estimates for pain among these physicians ranging from 35% to 60% of all respondents. Cervical spine disease, rotator cuff pathology, and degenerative lumbar spine disease were each reported by nearly one in five respondents in the pooled analyses, with increasing prevalence over the duration of the study period (JAMA Surg. 2017 Dec 27. doi:10.1001/jamasurg.2017.49).
These findings, called “worrisome” by the study’s authors, come at a time when the demand for surgeons and interventionalists is expected soon to outstrip supply, and point to a major stressor for a profession already plagued by high rates of burnout and depression.
The results of the study are in line with previous work that finds a high – and increasing – rate of pain and disability among at-risk physicians, who endure long work hours, awkward positioning, and few opportunities for breaks.
The study also suggested a possible linkage between work-related pain and other factors, such as burnout and depression, that lead to attrition in the surgical profession.
Adrian Park, MD, FACS, a general surgeon who has long studied the issue of work-related musculoskeletal disorders (MSDs) among surgeons and interventionalists, was not surprised by the study’s findings. “This just goes to further the narrative, which is a consistent one: These aren’t just sporadic instances of individual surgeons having a tough time; this is an increasingly broadly recognized problem. ... These are the consequences of surgeons simply getting up and going to work each week,” Dr. Park said in an interview.
To take a long view of the published data on work-related injury and pain for at-risk physicians, Ms. Epstein and her collaborators identified 126 articles reporting physician work-related MSDs that met quality standards; the studies spanned 1974 to 2016, and 23 countries were represented.
A total of 21 articles were eventually included in the meta-analysis, which included responses from 5,828 physicians. Most of the respondents were male (78.5%), with a mean age of 46 years and a mean 12.8 years in practice. The mean number of hours spent in procedures per week was 14.4.
Sixteen cross-sectional studies included in the meta-analysis examined injury prevalence, with 14 studies eventually meeting eligibility criteria for quantitative synthesis. A total of 4,245 physicians were included in this portion of the analysis; 1,232 were orthopedic surgeons, 1,118 were interventional cardiologists, and 582 were general surgeons (a variety of other subspecialties made up the remainder).
The career prevalence of degenerative lumbar spine disease was estimated at 19%, with prevalence increasing over time in a series of surveys of interventional cardiologists, said Ms. Epstein and her colleagues. Among this group, the prevalence climbed from 6.5% in 1997 to 24.7% in 2015, an increase in prevalence of over 18%, they said. The investigators’ estimate of lumbar spine disease prevalence from their own data also showed an increase, to 21%, for studies published within the past decade.
Rotator cuff pathology during the study period was estimated at 18% overall, and carpal tunnel syndrome at 9% overall; carpal tunnel syndrome also appears to be increasing in prevalence, estimated at 12% within the last decade.
Musculoskeletal pain that was judged to be work related was common, as reported in 18 cross-sectional studies. Taken together, the studies used a total of five validated tools that measured both pain prevalence and related disability. Twelve of the studies met criteria for inclusion in the quantitative synthesis.
Neck, back, and shoulder pain were all common in this group of surgeons and interventionalists. Neck pain had a 60% estimated 12-month prevalence, and shoulder pain was almost as common, with a 52% prevalence; back pain was reported for about half (49%) of respondents.
Just 10 of the included studies addressed disability burden, said Ms. Epstein and her colleagues. Overall, 12% of physicians responding in this subset of studies reported that they required work modification, leave of absence, or early retirement because of work-related MSDs.
In a separate arm of the analysis, Ms. Epstein and her collaborators looked at studies that discussed ergonomic assessments and interventions, using a qualitative approach. A total of 101 studies, 50 of them in the United States, were included. None of the studies, they said, “included long-term surveillance for work-related MSDs”; rather, they focused on short-term outcomes and, in some cases, on real-time electromyographic data.
Of the 101 studies looking at ergonomics, about a third (n = 38) looked primarily at ergonomically designed devices or technology, while another third (n = 37) focused on educational or behavioral interventions and modifications. These were the studies included in the investigators’ analysis.
A lack of awareness of ergonomic recommendations on the part of the surgeons themselves was identified in several studies. Several specialties, publishing in a total of eight countries, have put forward “at least one article describing a need for ergonomics education during medical training.” And, said the investigators, “A few studies have found that ergonomics education during medical training appears feasible, accepted, and effective at changing behaviors and reducing symptoms.”
In addition to the usual limitations inherent to the meta-analysis research design (selection bias, self-reported data, small samples of individual studies), the study was limited by the elusive nature of the topic. Work-related pain and disability among surgeons remains underreported and underestimated, according to both Dr. Park and the study investigators. Further research is needed, and the investigators wrote: “Ultimately, this work should be integrated with research on preventing surgeon burnout and attrition given shared risk factors.”
Micro breaks can help
What’s the solution? Dr. Park says that some fixes are low tech, and can be put in place immediately. He and his team implemented a series of brief breaks, taken every half hour during a procedure, that they dubbed “targeted stretching micro breaks.” These are 45- to 50-second breaks during which a series of exercise physiologist–designed brief stretches are undertaken that do not require breaking scrub.
In a study of 66 surgeons and operating room staff, Dr. Park, chair of the department of surgery at Anne Arundel Medical Center, Annapolis, Md., and his collaborators found that surgeons reported less pain and fatigue, and improved mental focus, when they took micro breaks during a procedure. When surgeons took micro breaks, operative time was no longer than when they didn’t take the breaks (Ann Surg. 2017 Feb;265[2]:340-6).
“We do this all the time in our operating room now,” said Dr. Park. “And it makes a difference in terms of pain, in terms of alertness, in terms of stamina. And it costs nothing.”
Major redesign of tools and workspace
Other targets for technological improvement include offering better-designed handles for laparoscopic instruments. “We’ve had one size fits all forever. Why has it taken us so long to recognize that there’s not one size of surgical hand?” asked Dr. Park. He made the point that the influx of women – whose hands are smaller on average than men’s – into the surgical professions makes this a particularly pressing issue.
“The high-tech piece is going to be a better understanding of the operative work flow,” said Dr. Park, calling for “a meaningful revisiting of the surgeon-device interface and the surgeon-patient interface.”
A fundamental redesign of the operating room will eventually be in order, he said, contrasting the surgeon’s environments with that of an airline pilot. In the cockpit, the pilot sees a “heads-up” display of a limited amount of data, with an eye to controlling the cognitive workload for the operator. By contrast, said Dr. Park, in the OR, there are “lights flashing, and things pinging,” and pieces of equipment don’t “talk” to each other, presenting sometimes overwhelming sensory input that just potentiates the stress of the environment. Operating room design, he said, should move toward an ergonomically improved and stimulus-controlled environment.
As the leader of the surgical team, and as a physician whose foremost concern is the patient on the table, the surgeon may inadvertently have fallen into a role where his or her well-being is neglected.
Dr. Park suggested that, in the surgical profession, “it has never felt safe or appropriate to talk about ourselves.” But for the good of the profession, and ultimately for patient care, “this has to change.”
Ms. Epstein and her coauthors reported no conflicts of interest. .