Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) has conducted an annual survey of its members for more than 20 years. The purpose of the survey is to provide a means of communicating the Governors’ concerns to the College leadership. The 2017 ACS Governors Survey, conducted in August 2017 by the B/G Survey Workgroup, had an 88 percent (241/274) response rate.
The following article focuses on Governors’ concerns regarding ergonomic injuries and the preventative steps they take to avoid these injuries.
Setting standards for the proper treatment of injuries was one of the motivating factors for the formation of the ACS. Under the direction of the ACS Committee on Trauma (COT), the College seeks to find evidence-based solutions to reduce the occurrence of injuries and their effects.
Businesses have long recognized the problem of injuries in the workplace. Even with the efforts of individual companies and government oversight agencies, such as the Occupational Safety and Health Administration, direct costs for job-related injuries average $15 billion–20 billion annually, with total annual costs reaching $45 billion–54 billion—an expense that companies and insurance groups typically absorb.*
These types of injuries are composed of a number of variables, including occupation, risks involved, and the requirements of the specific job, such as standing for long periods of time, lifting heavy objects, handling objects for extended periods of time, and so on. When injuries occur, businesses are prompted to change processes and to engage in innovative solutions to curb the opportunity for future incidents. Larger, more robust organizations have specific teams dedicated to tracking employee injury patterns and evaluating work processes for opportunities to reduce risks. Smaller organizations typically rely on outside consultants to evaluate the safety of their workplace environment and to make recommendations for improvement.
Consistent patterns of work-related injuries are a strong indication that innovative changes are necessary. For example, keying in the category and pricing information by hand during the checkout process at grocery stores eventually led to numerous cases of carpal tunnel injuries, which prompted a practice change. The result was the scanned bar code process, which led to a quicker checkout and a safer process for checkout clerks. Another example of a consistent pattern of work-related injury that led to a systemic change comes from the manufacturing industry. Many manufacturing companies changed the process for unloading delivery trucks after a large number of drivers developed back injuries and hernias that required surgery. These types of complaints also prompted manufacturing companies to train employees on strategies to avoid or decrease injuries. And, in many instances, lifting assist belts and increased mechanization were successfully implemented to reduce injuries and lost worker hours. As these examples indicate, labor-intensive occupations are at risk for injuries, and the medical field is no different from these professions, especially when it comes to performing surgery.
To better understand the extent of ergonomic injuries among ACS Governors, the 2017 B/G Survey posed a series of questions related to this topic. The results highlight a serious problem, as well as opportunities for our profession to develop work-related injury prevention strategies. This article focuses on several important revelations from the survey.
As surgeons, we are known for our dedication to hard work on behalf of our patients. We love what we do, and therefore, it takes a lot for us to slow down or stop practicing surgery altogether. Of the 241 respondents, 19 percent indicated they had a work-related injury, and 75 percent did not (see Figure 1).
Figure 1. Have you had a work-related injury?
Of the respondents who indicated they had experienced an ergonomic injury, 65 percent reported they had “undergone therapy, surgery, or stopped performing a procedure due to a work-related injury” (see Figure 2).
Figure 2. Have you undergone therapy, surgery, or stopped performing a procedure due to a work-related injury?
Many surgeons experience an array of physical challenges related to their work but continue to practice and take care of their patients. An examination of the U.S. demographics for surgeons reveals an increasing average age for these health care professionals. Similarly, 70 percent of survey respondents are 51 to 65 years of age, and only 15 percent are 50 years old and younger (see Figure 3). Some regions, such as rural settings, show an even greater increase in average age.
Figure 3. Age of Governors
Surgeons typically exhibit resilience and “get the work done” attitudes, but injuries can slow down anyone and, in some cases, lead to early retirement. Barriers, such as patients’ limited access to care, can place additional burdens on surgeons who choose to continue practicing, especially those with work-related physical ailments.†
In the 2017 B/G Survey, respondents were asked about the types of injuries they have sustained, as well as those sustained by colleagues. As expected, the types of injuries varied and were affected by specialty, although the results highlighted areas of concern that crossed specialties, such as those injuries involving the neck, lower back, knees, shoulders, and hands. For professionals who spend long hours at an operating table, deficits in these areas have cumulative negative effects on performance.
Known for their strong work ethic, surgeons typically don’t share with their colleagues when they are dealing with an injury. For example, although 41 percent of ACS Governors indicated they were aware of injured colleagues, 20 percent responded that they were unsure if a colleague had experienced a work-related injury (see Figure 4). It is likely that the 41 percent who were aware of injuries among their colleagues were referring to more obvious injuries that led to curtailed practice or time off for surgery.
Figure 4. Has a colleague had a work-related injury?
A growing problem in our profession is the reality that many surgeons are dealing with injuries while continuing to provide patient care. Compounding the problem is the lack of robust interventions to prevent these injuries. Our patient population is growing and the relative surgeon shortage is following a similar trend. If injury prevention strategies for our colleagues are not systemically implemented, the surgeon shortage will artificially increase and productivity will be hampered.
Manufacturing industries lower expenses by reducing injuries. When workers are unable to work because of job-related injuries, lost productivity and medical treatment expenses negatively influence the bottom line. Smart business leaders typically consider retaining workers and keeping them healthy more cost-effective than recruiting and training new workers.
Unfortunately, this survey has revealed that the medical profession is not taking care of its “workers” as well as other industries. Only 11 percent of ACS Governors who responded to the survey reported being part of a hospital system that has a program to address and prevent ergonomic injuries (see Figure 5).
Figure 5. Does your hospital/system have a program to address and prevent ergonomic injuries?
In several cases, respondents indicated that hospitals claiming to have injury prevention programs are “programs in name only.” Many of these hospitals rely on various policies and procedures to handle the problem, such as safety programs, posters depicting proper lifting recommendations, and bound instruction books that seldom leave shelves or desk drawers.
Innovative techniques have reduced hospital stays and improved outcomes. However, innovative procedures also result in surgeons learning new instruments and processes. It takes time and effort for surgeons to find the most effective approach to working with new systems or tools, although, in the end, these innovative techniques also provide hospitals and surgeons with ways to improve patient care. However, when queried, only 24 percent of the ACS Governors worked at a hospital and/or system that considered the ergonomic opinions of surgeons when considering new equipment (see Figure 6).
Figure 6. Does your hospital/system consider the ergonomic opinions of surgeons when buying new equipment?
Input from surgeons on the feasibility of new equipment could include the following considerations: Do the new instruments fit the hands of all surgeons who could potentially use them? How manageable are the new operating room lights to maneuver and/or set in place? Will the new stretchers in the clinic adjust enough to prevent back injuries?
The constant challenge of implementing preventive strategies to help surgeons avoid ergonomic injuries is reminiscent of “The Upstream Story,” which is often considered a public health parable. In the story, a strong swimmer is on the river bank of a fast-moving stream. The swimmer starts to see drowning individuals in the river and swims out to save and bring them to shore. After rescuing several thankful victims, the swimmer ventures upstream. The swimmer is then questioned for leaving instead of staying and rescuing others who might be caught in the strong current. Why is the swimmer leaving? The swimmer wants to learn why people are falling into the river and address the problem at its source rather than just focusing on the end result. Likewise, surgeons treat the injured, but they also seek out the source of injuries to prevent future injuries in other patients. The same approach may be employed when investigating the source of work-related injuries that physicians sustained.
The good news
Although this survey did produce several alarming statistics, it also revealed some good news. The discussion of ergonomics is more prevalent than ever and is increasingly a priority for leaders in the health care profession. In the survey, 80 percent of ACS Governors responded that they consider ergonomic issues when beginning a surgical procedure. Only 5 percent said they do not give this consideration before starting a surgical procedure. In fact, surgeons, especially our younger colleagues, are increasingly focused on ergonomics (see Figure 7).
Figure 7. Do you consider ergonomic issues when beginning a surgical procedure?
The first step for process improvement of any kind is to recognize that a problem exists, and to recognize the opportunity for positive change. At Clinical Congress 2017, the Advisory Council for General Surgery and the Advisory Council for Rural Surgery offered an in-depth educational program on ergonomics. At Clinical Congress 2018, the B/G Physician Competency and Health Workgroup and the B/G Survey Workgroup will host another session relevant to this topic.
Similar to the strong swimmer described earlier, surgeons are not only focused on aiding injured colleagues, they also want to prevent the problem from occurring. Governors have indicated they are focused on ergonomic issues before beginning cases. Although these considerations vary by specialty, some significant ergonomic issues that surgeons take into account include the following: paying attention to table height (96 percent); noting the lighting situation and arrangement (75 percent); assessing the monitor height (69 percent); and paying attention to the room equipment and how it is arranged (65 percent) (see Figure 8). As obesity levels in the patient population continue to rise, it is important to ensure hospitals have patient transfer capabilities that avoid injury to physicians and staff.
Figure 8. What types of ergonomic issues do you consider?
Identifying the ergonomic strategies that ACS Governors and other surgeons use to prevent work-related injuries in the operating theater is just a first step toward addressing this issue. Investigating the topics that arise by asking the following assessment questions are another way to prevent work-related injuries: When new instruments are considered by a hospital system, should surgeons ask more questions? Who are the equipment manufacturers’ “customers” when they make changes to their designs and equipment? How can surgeons help themselves and their colleagues avoid injuries while also maintaining their productivity and providing quality care to patients?
In addition to treating our colleagues who are injured and covering for them as they recuperate, surgeons must travel upstream and find the source(s) of the problem(s). But how do physicians start this evaluation process? Small steps include developing a personal “ergonomic timeout,” discussing ergonomic considerations at surgery department meetings, as well as getting involved when it’s time for OR renovations and equipment purchase planning.
*U.S. Department of Labor. Occupational Safety and Health Administration. Statement of Charles N. Jeffress, Assistant Secretary for Occupational Safety and Health, U.S. Department of Labor. April 27, 2000. Available at: www.osha.gov/news/testimonies/04272000. Accessed April 24, 2018.
†American College of Surgeons. The Governor’s Committee on Physician Competency and Health. Being well and staying competent: Challenges for the surgeon. 2012. Available at: facs.org/~/media/files/member%20services/being_well_and_staying_competent.ashx. Accessed April 24, 2018.