Q&A: Ergonomics key to preventing injury, improving well-being of endoscopists
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Optimal ergonomics plays a critical role in preventing endoscopy-related injury by enhancing safety in practice and, thus, extending career lifespans.
Healio sat down with Catharine Walsh, MD, MEd, PhD, FRCPC, associate professor of gastroenterology, hepatology and nutrition at the Hospital for Sick Children and in the department of pediatrics at Temerty Faculty of Medicine at the University of Toronto, to talk about the importance of ergonomics and how to implement it into practice.
Healio: Why is it important to explore optimal ergonomics in endoscopy?
Walsh: Ergonomics, as it relates to endoscopy, seeks to understand endoscopists’ interactions with elements of their work environment, including the endoscopy equipment and the endoscopy unit, and examine how these can be redesigned to reduce the risk of endoscopy-related injury, improve endoscopist well-being and optimize overall system performance.
We know endoscopy-related injuries are quite common among pediatric gastroenterologists, and we can use principles of ergonomics to mitigate risk factors in endoscopists’ work environment and reduce the risks of endoscopy-related injuries. It is time that we bring the importance of endoscopists’ well-being to the forefront of practice.
Healio: How common are endoscopy-related injuries and which ones are most prevalent?
Walsh: Endoscopy-related injuries are quite common among pediatric gastroenterologists. In a recent study I carried out with Wenly Ruan, MD, Douglas Fishman, MD, and other colleagues, we surveyed 146 pediatric gastroenterologists and trainees who attended the 2019 NASPGHAN Annual Meeting. Of the gastroenterologists we surveyed, 36.5% of faculty and 30% of trainees reported experiencing a musculoskeletal injury attributable to endoscopy. These rates are only slightly lower than those reported in the adult survey-based literature, which indicates that between 39% and 95% of practicing adult endoscopists and 20% to 49% of trainees have experienced endoscopy-related injuries.
Perhaps what is more sobering is that 8% of pediatric endoscopists in our recent survey reported that they had taken time off from performing endoscopy due to an endoscopy-related injury, 32% reported adjusting their practice and 24% received treatment for an injury. The most common sites of injury reported among pediatric gastroenterologists in our study were the back, neck and upper extremities, particularly the thumb, hand, wrist and figure pain.
Healio: What risk factors are associated with repetitive strain?
Walsh: The performance of endoscopy places unique strains upon the body, which are known risk factors for work-related injuries. These include forces on the forearms, wrists and thumbs during torque of the insertion tube and adjustment of the endoscope dials, and on the neck and back from looking at the monitor and twisting to manipulate the endoscope. Endoscopy also requires prolonged periods of standing, repetitive motions and can involve awkward positioning, all of which place the endoscopist at high risk for musculoskeletal injury.
Risk factors for endoscopy-related injury that have been seen in adult literature include higher procedure volume (specifically more than 20 cases per week or more than 16 hours of procedures per week) and more years performing endoscopy. Adult studies also have found that prior injury is a risk factor for subsequent injury, which speaks to the importance of preventative care and identifying factors before they become problematic.
Research examining the relationship between gender and injury risk in adult practice has yielded mixed results. However, in our recent pediatric study, we did find that women reported experiencing endoscopy-related injuries more frequently compared with men (43.4% vs. 23.5%).
Healio: What can be done to mediate the ergonomic gaps in practice?
Walsh: Despite the clear prevalence and impact of endoscopy-related injury, very few pediatric endoscopists learn about ergonomics. In our recent survey, only 20.9% of pediatric gastroenterologists reported receiving formal ergonomics training, and research has shown that education can improve ergonomic-related behaviors. As not all centers have individuals with expertise in endoscopy ergonomics, there remains a need to develop educational resources that can be used across training sites.
I recently helped lead the development of an American Society for Gastroenterology core curricula for ergonomics in endoscopy, which can be used by program directors, faculty and trainees as an overview of ergonomic principles relevant to the performance and training of endoscopy. This hopefully will inform the development of future educational resources to help ensure trainees develop safe and effective techniques at the start of their careers to enhance endoscopist safety and extend their career lifespans.
It also is essential to develop educational resources for practicing endoscopists to help them better understand the importance of adopting good ergonomics habits and enable them to teach principles of ergonomics effectively. During procedures, faculty are often focused on teaching endoscopy techniques to trainees, but it is equally important for them to teach and provide feedback around ergonomics. Trainees are often so focused on the monitor they may not notice they’re standing in an odd position.
Recent research I conducted with Rishad Khan, MD, and Samir Grover, MD, MEd, has highlighted the usefulness of simulation-based training for teaching ergonomics and ergonomics-specific checklists that can be used by endoscopists to facilitate real-time optimization of ergonomics before and during procedures and to help guide trainee learning and feedback provision.
An “ergonomic time out” ahead of a procedure also is useful as a reminder for all team members to check their posture, bed and monitor height, and other elements of proper ergonomics.
Healio: What advice do you give to endoscopists to improve ergonomics in practice?
Walsh: Although the performance of endoscopy inherently places the endoscopist at risk of injury, there are numerous things that can be done to improve ergonomics in practice. At an individual level, it is critical for endoscopists to be aware of important ergonomic principles that can be used to mitigate the risk for injury, including adoption of a neutral, “athletic stance’” during endoscopy. Proper endoscopic technique is also key, including adoption of a neutral grip and use of facilitated torque steering, whereby torque is applied predominantly using the larger muscle groups of the left arm as opposed to the right wrist. Additionally, I would encourage endoscopists to use devices such as cushioned floor mats, which can help to reduce strain during endoscopy, and to implement personal care strategies, such as preventative stretching between cases.
At a center level, it is important that endoscopy suites are designed with flexibility in mind to help decrease the risk for endoscopic-related injury. For example, inclusion of adjustable monitors and beds that allow for neutral postures during the performance of endoscopy and equipment that is movable to ensure the monitor can be positioned directly in front of the endoscopist at an appropriate distance (52 cm-182 cm) and height (15 degrees-25 degrees below the horizon) to minimize strain. Additionally, workplace policies and practices can be adapted to promote safe ergonomic practices, such as integration of microbreaks between cases to help relieve muscle tension or altering endoscopy schedules to ensure adequate time for recovery between shifts.
At a broader level, we as a pediatric endoscopy community need to work with industry to develop a safer and more user-friendly endoscope and other endoscopy equipment. Equipment should be designed so that it is safe for everyone to use and can accommodate endoscopists of all shapes and sizes, from the 5th percentile woman to the 95th percentile man.
Healio: What were the key takeaways from your NASPGHAN talk?
Walsh: As physicians, we are constantly striving to take excellent care of our patients. However, we often fail to take good care of ourselves. As endoscopists, we have physically demanding jobs and efficiency is often emphasized. Endoscopy-related injuries are common, yet pediatric endoscopists are not well-educated with regard to ergonomics and injury prevention. It is my hope that this talk helped increase endoscopists’ awareness of things they can do to improve ergonomics in their own practice, as well as what can be done at a center level to ensure we create ergonomically sound workspaces to help preserve physician health and well-being. Education and prevention of endoscopy-related injury is key.
Healio: Is there anything else you’d like to add on this topic?
Walsh: To date, research in the field of endoscopy ergonomics has been predominantly survey-based. Looking to the future, there is a need for more research focused on developing and evaluating interventions that can help pediatric endoscopists’ optimize ergonomics in practice and strategies, such as stretching, that can be used to help prevent and alleviate endoscopy-related injuries.
References:
Ruan W, et al. Gastrointest Endosc. 2020;91(6s):AB500.
Walsh CM, et al. Gastrointest Endosc. 2021;93(6):1222-7.
Khan R, et al. Gastrointest Endosc. 2020;doi:10.1016/j.gie.2020.03.3754.
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