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How Surgical Ergonomics Impact Surgeon Wellbeing, Outcomes, and Careers

by Julie L. Wei, MD, MMM •

At this year’s American Society of Pediatric Otolaryngology Annual Meeting at the Combined Otolaryngology Spring Meetings in Boston, I was grateful to moderate a panel of experts I assembled on surgical ergonomics. This topic is highly personal to me and has impacted colleagues I know in otolaryngology who’ve suffered unanticipated and devastating career-ending injuries.

Despite a few recent publications in surgical journals that include otolaryngology, there remains a lack of awareness by surgeons and no standardized curriculum for trainees and practicing otolaryngologists on the prevalence of surgeons who endure pain and discomfort on daily basis. Ergonomic hazards and work-related musculoskeletal disorders (WRMSD) are among the most impactful, yet unrecognized, occupational hazards for all surgeons.

Our panel was titled, “Pain in the Neck (and More): How Surgical Ergonomics Impact Surgeon Wellbeing, Outcomes, and Careers,” and my esteemed panelists were:

  • Tendy Chiang, MD, a pediatric otolaryngologist who presented his research on methods to measure and mitigate ergonomic risks.
  • Daniel Wohl, MD, a pediatric otolaryngologist who shared pearls and strategies for best ergonomic practices in the operating room and in clinic when examining patients.
  • Donald Shrump, Jr., DC, MS, a chiropractor, sport science expert, collegiate and elite athlete trainer, and researcher. He presented information on functional standards and surgeon- specific training to address neck, shoulder, and back pain.
  • Stephanie Pearson, MD, an OB/ GYN who suffered a devastating, career-ending injury during a delivery seven years ago. She’s the founder of PearsonRavitz Disability Insurance, and she’s passionate about educating and helping physicians achieve professional protection through disability insurance.
  • Geeta Lal, MD, an endocrine oncology surgeon, ergonomic coach, and speaker who is also president of the Society of Surgical Ergonomics.

While I wish you could all enjoy a video recording, that isn’t available, so this article will share key points from each panelist as well as actions that my fellow otolaryngologists can implement immediately.

Julie L. Wei, MD, MMM

As moderator of our presentation, I shared the results of our most recent surgical ergonomic survey deployed three weeks prior to the ASPO meeting. This survey was developed by Andrew Gabrielson, MD, a PGY-5 in urology at Johns Hopkins University and member of the Society of Surgical Ergonomics. The survey collected variables, including surgeon demographic, practice setting, surgical volume, procedure types, work-related musculoskeletal pain-related metrics, modifying factors, and knowledge of/attitude toward surgical ergonomics.

A total of 685 were sent the email survey; 118 practicing pediatric otolaryngologists completed it. This manuscript is currently submitted for publication, but as senior author I shared our key findings:

  • 78% of respondents reported current or prior pain and/or injury attributed to performing surgery—20% higher than reported in a 2012 survey.
  • The most affected areas were the neck/cervical spine (63%), shoulders/arms (44%), lower back/lumbar spine (36%), and hands/wrists (31%).
  • Half of the respondents were diagnosed with musculoskeletal condition( s) attributed to performing surgery.
  • Two-thirds required treatment (62% pharmacologic only, 9% pharmacologic and surgical intervention) for their work-related pain.
  • Using intermittent pauses during procedures to adjust body position was the most reported method of addressing pain in the operating room (50%), followed by ignoring the problem/working through the pain (48%).
  • Only 21% reported ever receiving ergonomic training during their career, but 92% desired surgical ergonomic training.
  • 91% would be willing to incorporate intraoperative stretching.
  • 65% would be willing to incorporate ergonomic checks into current pre-incision timeouts.

Results from a 2019 survey from 569 endoscopic surgeons (84% males and 94% right-handed) indicated that more than 62% of surgeons reported their worst pain score as a 3 or higher on a 10-point scale in past week, encompassing 71% of open cases, 72% of laparoscopic cases, 48% of robot-assisted cases, and 52% of their endoscopies done. Of the 120 surgeons who reported ever seeking medical help for pain or discomfort, 38% were currently in pain, 16% had considered leaving surgery due to their musculoskeletal pain, and 26% had been on short-term disability at some time during their careers. These surgeons reported significantly lower satisfaction from their work, higher burnout, and significantly higher callousness toward people than those not fearing the loss of career longevity (Surg Endosc. 2019;33:933–940).

Julie L. Wei, MDErgonomic hazards and work-related musculoskeletal disorders (WRMSD) are among the most impactful, yet unrecognized, occupational hazards for all surgeons. —Julie L. Wei, MD, MMM

Another report, published in the same year in The Laryngoscope (2019;129:370–376), focused on ergonomic hazards in otolaryngology. This intraoperative observational and survey study used the Rapid Entire Body Assessment scoring system to identify hazards during different subspecialty procedures and a survey to evaluate ergonomic practice, environment infrastructure, and prior ergonomic training/education. Of 70 surgeons at a single institution (a 69% response rate), 72.9% reported suffering from some level of back pain, with cervical spine pain being most common. Residents experienced the same level of pain as more senior surgeons, with 43.8% of surgeons reporting the highest level of pain when standing compared to 12.5% when sitting, 10% reporting that pain had impacted their work as surgeons, and 24% reporting having no prior ergonomic training.

I’m grateful to be resuming my clinical and surgical career this fall. I’ve endured three years of WMSD, from initial frozen shoulder (adhesive capsulitis) symptoms in 2019 that persisted despite injections, and then, after shoulder decompression surgery, a significant loss of range of motion from my right frozen shoulder and chronic shoulder pain from April 2021 to December 2022. That was followed by cervical radiculopathy from November 2021 to July 2022. A chance to now return to a career I love is a gift beyond description.

I now know the reasons for why I’ve experienced the unimaginable in terms of MSK. I’ve worked over 20 years with poor surgical ergonomics as a pediatric otolaryngologist with poor surgical ergonomics, and suffered excessive neck flexion for countless adenotonsillectomy cases, use of binocular microscopes and loupes for open cases and LTRs, chronic stress with tension carried in my neck and shoulders, poor compensatory and weak muscles, lack of core strength, reaching menopause at 40, holding asymmetric body positions, never stretching before, during, or after OR cases and clinic days, and there were some whiplash injuries from few car accidents in my early adulthood.

Tendy Chiang, MD

Dr. Chiang discussed a study he published in 2020 to demonstrate ergonomic risk in pediatric otolaryngology. His team used Rapid Upper Limb Assessment and calculated the risk of musculoskeletal loading within the upper limbs and neck, confirming that ergonomic risk is quantifiable and found in high-volume procedures such as adenotonsillectomy and tympanostomy. In fact, 100% of cases were performed with increased ergonomic risk. (Otolaryngol Head Neck Surg. 2020;163:1186–1193).

That study was followed up with a study published last year on using craniovertebral angle to quantify intraoperative ergonomic risk. (Otolaryngol Head Neck Surg. 2022;167(4):664–668). The authors reported the following:

  • The craniovertebral angle (CA) is defined as abnormal if it’s < 50°.
  • All surgeons had an abnormal CA while performing tonsillectomies, with an average CA of 24.9°.
  • There was a high interrater reliability.
  • The CA can be used to quantify the effects of ergonomic interventions such as vibrotactile biofeedback.

Dr. Chiang’s most recent study was on the association of vibrotactile biofeedback with reduced ergonomic risk during tonsillectomy (JAMA Otolaryngol Head Neck. 2023;149:397–403) Conclusion from this study included the following:

  • Common surgeries place us at substantial ergonomic risk for injury.
  • Vibrotactile biofeedback significantly reduces neck, back, and trunk ergonomic risk.
  • Ergonomic interventions and education have the potential to prevent WMSD and improve overall quality of life.

Daniel Wohl, MD

Next, Dr. Wohl shared the following ergonomic pearls regarding the OR and clinics with the audience:

  • Ensure that the neck and back are in alignment. Avoid overflexion of the neck and forward head posture, as both increase neck pain. Surgeons should maintain a neutral position as much as possible.
  • Align the neck, back, and hips while operating.
  • Ensure that the OR table height and monitor placement are at eye level and support a neutral craniovertebral position without strain.
  • Stabilize the arms to ensure good neck and back alignment when performing an airway endoscopy.
  • Adjust your seat, back rest, and arm rest, and use the arm stabilizer, as well as optimal patient positions, to support good ergonomics.
  • Do passive stretching in the OR before, after, and between cases.
  • Raise your arms and use I-beam clamps for straight arm lean and bent arm hang.
  • Ensure that you have good neck and back alignment when examining patients.
  • Never delay intervention once symptoms appear.

Donald Shrump, Jr., DC, MS

Dr. Shrump has worked with elite athletes around the world in countless professional sports organizations, including the NFL, NBA, NHL, MLB, MLS, NCAA, and organizations that work with elite junior athletes.

During his presentation, Dr. Shrump highlighted the fact that neck, back, and shoulder pain all require breathwork, stretches, intra-op optimizations, microbreaks, and awareness. Specifically, progressive training in deep cervical deep flexors, the core, and arms are needed for neck, back, and shoulder pain, respectively. Dovetailing with my recent ENTtoday article on wearable technology (see the May 2023 issue), Dr. Shrump also highlighted wearables surgeons can try to improve posture and ergonomics.

Dr. Shrump also mentioned data-based gender-specific differences in the risk of musculoskeletal (MSK) injury from professional athletic training that has changed the demand and training schedule for elite female athletes according to their menstrual cycles. Hormonal changes before, during, and right after their cycles increase the risk for women to suffer MSK injuries and impact their performance. It makes sense, and yet I wonder how many others in the audience felt a moment of discomfort. I did—after all, who would mention physician menstrual cycles at a national surgical scientific meeting? Although the culture of surgical training has traditionally been dominated by males, and being a female subjects trainees and surgeons to existing implicit and explicit biases regardless of our efforts, skills, and accomplishments, bodily functions like menstruation do have a scientific effect on our bodies.

Stephanie Pearson, MD

“Ergonomics is the No. 1 cause of all disability insurance claims, as work-related musculoskeletal disorders are highly prevalent,” Dr. Pearson told the audience. “The cost to the physician isn’t limited to their difficulty/inability to perform their job. There’s a physical, mental, and financial toll on the individual. There’s pain management, loss of identity, depression, and standard of living issues. Many physicians will continue to practice in pain instead of acknowledging that they aren’t OK—until it’s too late.”

Many physicians will continue to practice in pain instead of acknowledging that they aren’t OK—until it’s too late. —Stephanie Pearson, MD

For surgeons, the most common injuries include carpal tunnel issues, rotator cuff tears, labral tears, and back, neck, and arm issues. Dr. Pearson emphasized that women are at greater risk of suffering disability than men, and additional factors include surgical instruments that are not designed for the smaller-sized hands of most female surgeons and are designed for right-handed surgeons. Additional risks include the heavy lead vests and poor stools used in ORs.

“I hope that with increased awareness and prevention, these disabilities will decrease,” said Dr. Pearson. “In the meantime, it’s important to secure quality disability insurance early in your career to protect yourself from such an event. Part of obtaining coverage involves medical underwriting. Body parts will be excluded from coverage if you already have imaging with changes or subjective complaints with or without treatment. The goal is to have head-to-toe coverage if years of wear and tear take their toll.”

Geeta Lal, MD

Dr. Lal’s keynote highlighted relevant data, research, and compelling perspectives on risks to surgeons, particularly the increased risk of injury for female surgeons. Otolaryngologists are at high risk of MSK injury partly due to using headlamps and loupes, maintaining a fixed position for prolonged periods for endoscopic sinus surgeries, using binocular microscopes, and performing a high number of procedures that require excessive neck flexion.

Susan Hallbeck, PhD, a professor of healthcare systems engineering and a consultant in both surgery and healthcare delivery research at the Mayo Clinic, has shown that the OR stretch results in better physical performance, increased mental focus, decreased pain and discomfort, and decreased fatigue when used routinely.

I hope this article increases your awareness of ergonomics, and I wish you a healthy and lengthy career without pain, discomfort, or disability.

Dr. Wei is chair of otolaryngology education for the University of Central Florida College of Medicine. She is also an associate editor on the ENTtoday editorial advisory board.