Watch your back!
Focusing on ergonomics can help dermatologists avoid a career-ending injury.
Feature
By Ruth Carol, contributing writer, February 1, 2021
After a long day of seeing patients, performing dermatologic procedures, or reviewing slides, do you have stiffness in your neck, pain in your back, or maybe an aching in your shoulders? Aspirin may provide temporary relief, but if left unchecked, these aches and pains could cost you your career.
Non-fatal occupational injuries and illnesses in the health care field surpass those in all private industry sectors, including manufacturing, according to a 2018 report issued by the U.S. Bureau of Labor Statistics. Health care job-related injuries cost upwards of $20 billion a year, noted David Welsh, MD, FACS, a general surgeon in private practice in Batesville, Indiana, who has spoken about ergonomics at American Medical Association annual meetings, and has contributed to related articles and educational programs for the American College of Surgeons.
The good news is that work-related musculoskeletal disorders (MSDs) can be prevented. That’s where ergonomics comes into play. The Occupational Safety and Health Administration defines ergonomics as the “science of fitting the job to the worker.” When the physical requirements of the job do not match the physical capacity of the worker, work-related MSDs can result.
It’s not just MSDs. Poor ergonomics also cause microtrauma, Dr. Welsh said. “If you don’t pay attention to these injuries, you will need an intervention, which could be physical therapy, an exercise program, surgery, or you may have to stop working.”
“If you don’t pay attention to these injuries, you will need an intervention, which could be physical therapy, an exercise program, surgery, or you may have to stop working.”
Dermatologists included
Dermatologists are high on the list of specialists subject to MSDs. In a 2010 survey of 354 Mohs surgeons conducted by the American College of Mohs Surgery, 90% of respondents reported some form of musculoskeletal symptoms or injuries. The four most common problem areas were the neck, lower back, shoulders, and upper back. In a 2007 survey of Mohs surgeons at Mayo Clinic, 16 of the 17 respondents reported musculoskeletal symptoms caused or made worse by performing surgery. In both studies, MSDs presented early in the dermatologic surgeons’ careers and persisted throughout it.
Dermatologists perform some of the highest numbers of procedures among any specialty, noted Ashish C. Bhatia, MD, associate professor of clinical dermatology at Northwestern Medicine in Chicago. Among them are biopsies, cryosurgery, injections, excisions, laser surgery, and Mohs surgery with reconstructive repairs. Dermatologists tend to hunch and lean forward with their neck extended, putting a significant amount of strain on their cervical spine, he said. Additionally, sitting at the microscope for hours without a break, as dermatopathologists often do, can lead to a “locked-in” posture.
Early in his career, Dr. Bhatia had some muscle strains and neck soreness. Other than taking over-the-counter anti-inflammatory medications, he did not address them. Ten years ago, he had a cervical fusion followed by a lumbar fusion five years ago. After his experience, Dr. Bhatia spoke to other dermatologists to learn that many of them also had MSDs. “Some have been able to correct their musculoskeletal injuries with physical therapy and practice modifications while others have had to have surgery,” he added. One of his mentors, a Mohs surgeon, had to stop performing surgery altogether.
Like Dr. Bhatia, Patrick Lee, MD, a professor of dermatology, and director of dermatologic surgery in the department of dermatology at University of California, Irvine, experienced MSDs — only his developed later in his career. After practicing for 25 years, he had developed age-related degenerative changes and a partially herniated disc. Cervical traction, which he continues to use, helped relieve his symptoms and eliminated the need for surgery. Dr. Lee is not surprised by how many dermatologists have MSDs, but rather the dearth of information about dermatology-specific ergonomic guidance. In a recent paper he co-authored and published in Dermatologic Surgery, a search of PubMed and Cochrane Reviews databases from 1975 to 2019 generated only six publications from the dermatology literature. In contrast, 58 publications were found in the fields of dentistry, medicine, and select surgical subspecialties. Fortunately, many of the lessons learned in other specialties can be applied to dermatology.
Ergonomics 101
Drs. Lee and Bhatia believe that ergonomics should be covered in dermatologic training. In 2017, Dr. Bhatia surveyed second- and third-year residents to learn that the majority did not receive any formal education in ergonomics or how to prevent MSDs.
In the meantime, they take it upon themselves to educate residents about ergonomics. Dr. Lee is always telling residents to “stand up straight and watch your neck” when he sees them performing a procedure. He has noticed that residents tend to crane their neck out, which leads to cervical neck problems. Every so often, Dr. Lee tells the residents to stop and look down their own shirt. If they must tuck in their chin, it means their neck is extended too far. Residents also tend to bend at the waist. Dr. Lee suggests that they bend at the knee, more like a squat, to support their lower back and keep it straight. “I’m really a bit of a nag,” he added.
The worst thing that can happen is they get a good surgical result while operating in an awkward, or ergonomically unfavorable, position because it is difficult to change a technique that has resulted in success, Dr. Lee noted. He often talks about ergonomic positioning while demonstrating it.
“We don’t think about these things as a resident or an early career dermatologist,” Dr. Bhatia said. “We think we are tough, and we will muscle through whatever comes our way.” During his pre-COVID-19 lectures to residents about ergonomics, loupes, positioning, etc., Dr. Bhatia stressed the importance of listening to their bodies. If residents start getting MSD symptoms, he advises them to take the symptoms seriously, and have them evaluated sooner rather than later to determine the underlying cause. “As they say, an ounce of prevention is worth a pound of cure,” Dr. Bhatia said.
Make practice modifications
Modifications to equipment in the office can help prevent MSDs. The following are examples that have been found to be beneficial.
Examination and surgical tables. Examination and surgical tables should be adjustable to accommodate the physician’s height, either sitting or standing, Dr. Lee said, adding, “You need to be able to get in close to the patient, but also have your head and neck supported.” Dr. Bhatia concurred. “Even if you bend your head forward an extra five degrees, that adds a significant amount of stress to your discs and cervical spine, which can lead to ruptured or herniated discs.” Dermatologists sometimes end up in awkward positions because they work on all parts of the body, but the amount of time spent leaning over the patient can be minimized with a properly adjusted table. Dr. Bhatia noted that the price of tables can vary by thousands of dollars. “But if it helps you operate more efficiently and comfortably and keeps the patient safe and comfortable as well, spending more is worth it,” he said.
Lighting. Dr. Lee prefers adjustable, ceiling-based lighting centered above the table. Overhead lights with moveable arms enable the physician to hover over any part of the patient being looked at or worked on and pinpoint certain areas to reduce shadowing, he said. Dr. Bhatia uses three types of lighting in his office: ambient light in the exam room, surgical light in the operating room, and a hand-held light with magnification or a dermatoscope. Lighting should match the task at-hand, he said. While blue light is very bright and brilliant, it can cause headaches. Lights in the operating room should be a truer white to help illuminate the surgical field.
Chair. A contoured chair is ideal for reviewing slides and head and neck surgery, enabling the physician to stand or sit next to the patient or microscope, Dr. Lee said. A wide chair works well for heavier patients and examinations or procedures involving the trunk and extremities, but it should not be so wide that the physician will have to lean over the patient.
Trays. Trays should be adjusted for the dermatologist’s height and positioned so that they can slide in close to them, Dr. Lee said. They should be laid out efficiently so that the physician doesn’t have to strain to reach instruments. Dr. Bhatia used to have his assistant stand on the opposite side of the table, which meant that the assistant had to lean further to get instruments. Now, they stand at a 90-degree angle from each other, helping to relieve strain for them both.
Magnification eyewear. These devices include bifocal magnifying glasses, magnification visors, magnifiers with frame, and loupes, all of which can promote better posture while preventing eyestrain. Dr. Bhatia switched to customized loupes set for his focal distance. “They force me to keep my head back in an ergonomically correct position. If I get closer than I should be, they go out of focus,” he said, adding. “I consider them a very expensive pair of glasses, but in the long run, it’s a small investment.”
Microscopes. An ergonomically friendly microscope should have an extendable binocular observation tube, adjustable observation angle (0-25 degrees), and maintain an upright posture with 90-degree angle between the physician’s spine and forearms, Dr. Lee said. Dr. Bhatia prefers to stand when he uses the microscope. Getting one with oculars that rotate up and down do not require the physician to bend forward. One of his locations does not have that kind of microscope, so he built a stand to elevate it.
Computer workstation. When on the computer, no doubt working on electronic health records (EHRs), think of a concert pianist who maintains the best posture, Dr. Lee said. “Make sure your chair is the perfect height for the keyboard and your feet are firmly on the floor in the proper position spaced apart.” When on the phone, consider using headsets to prevent positioning your head to one side, which puts a strain on the vertebrae and discs, Dr. Bhatia noted. This also enables the dermatologist to be on the phone and document on the EHR simultaneously. “We have found that just sitting at your computer doing EHRs contributes to these injuries,” Dr. Welsh added.
Adopt an ergonomic approach
Simple changes to one’s posture and positioning can help avoid developing MSDs. A prime example is to sit up straight and stand tall when performing procedures or doing microscope work. “Mom was right. Posture is important,” Dr. Welsh said. Other tips include change positions often, avoid putting too much stress on one part of the body, and turn the entire body instead of twisting it. Both Drs. Bhatia and Lee alternate between sitting and standing when performing surgery.
Dermatologists should prepare themselves for those long days of surgery, in-office procedures, or microscope work with a wellness program that includes exercises targeting the upper back and neck, Dr. Welsh said. “You want to prepare for those days just like prize athletes prepare for a big game,” he said. Drs. Bhatia and Lee both have exercise regimens that include strengthening and stretching the muscles that support their neck, back, and shoulders.
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They are also proponents of taking 20- to 30-second breaks every 30 or so minutes. Whether doing chairside stretches or standing wall exercises/stretches, studies show that taking 20 seconds every 20 minutes to stretch can help reduce pain and decrease injury, Dr. Welsh noted. Dr. Lee keeps a foam roller in the office to stretch and loosen stiff muscles. He does stretches between cases and at lunch time. “Thirty seconds every 30 minutes makes a huge difference,” he said. “The biggest thing that has helped me is being mindful of feeling strain and stress,” Dr. Bhatia said. Other tips include wearing compression socks and using anti-fatigue mats.
Seek a professional opinion
If unsure how to adopt an ergonomic approach, consider getting a professional opinion. Dermatologists in small or solo practice should consider asking a co-worker to videotape them during routine cases, and then consulting with a physical therapist to evaluate their posture/positions and provide suggestions for improvement, Dr. Welsh recommended. “The only way to evaluate this is have someone observe you,” said Dr. Bhatia, who had a resident observe and photograph him during a routine workday. As a result, Dr. Bhatia was able to correct some posture and positioning issues. Another option is to hire a certified ergonomist to study how the practice is set up and provide recommendations to improve it, Dr. Lee said.
If affiliated with a large institution, consider asking other specialists about their best practices, Dr. Bhatia suggested. Who better to ask about computer, keyboard, and office chair recommendations than radiologists who sit for hours in front of a computer screen looking at films? What helps orthopedic and cardiac surgeons stand for hours performing surgery? Some of the best information on sitting while operating comes from the ophthalmology and ears, nose, and throat literature. Physiatrists can provide a wealth of information as the experts in treating MSDs, he said.
In the end, ergonomics is about self-care. Dermatologists are used to taking appropriate precautions for needlesticks and blood splatters, he said. They must also take precautions to ensure they have a long and full career by taking good care of themselves. That includes getting plenty of rest and exercise. “Remember that the best way to treat an ergonomic injury is to avoid it,” Dr. Welsh concluded.
