Ergonomics in dermatology

By Ruth Carol, Contributing Writer, January 1, 2025

After investing an average of 12 years of education and training, the last thing a dermatologist wants is to have their career cut short by musculoskeletal disorders (MSDs). However, it can — and does — happen if MSDs are not addressed early on. Common issues for dermatologists include neck stiffness, back pain, and shoulder aches. At some point, these symptoms may require treatment, ranging from physical therapy to surgery. Fortunately, office equipment can be ergonomically configured, and dermatologists can adopt work habits that promote proper posture and positioning to ensure a long and healthy career.

Although a doctor’s office might not be the first place that comes to mind when thinking of a dangerous work environment, non-fatal injuries in the health care field exceed those in all private industry sectors, including manufacturing, according to the U.S. Bureau of Labor Statistics’ latest figures. Work-related MSDs are among the most frequently reported causes of lost or restricted work time, reports the Occupational Safety and Health Administration (OSHA).

Prevalence among dermatologists

Studies show that dermatologists experience a high prevalence of MSDs. About 90% of respondents reported some form of musculoskeletal symptoms or injuries in a 2010 survey of 354 Mohs surgeons conducted by the American College of Mohs Surgery. In a 2007 survey of Mohs surgeons at the Mayo Clinic, 16 of the 17 respondents reported musculoskeletal symptoms caused or made worse by performing surgery.

Female dermatologists have higher incidence of work-related MSDs based on survey responses, noted Jonathan Cook, MD, FAAD, professor of dermatology and assistant professor of surgery at Duke Health in Durham, North Carolina. Females in general have higher incidence rates of many musculoskeletal complaints and they are not always work-related. One work-related factor for females could be that office equipment and workstations are often too tall for women to work comfortably.

“Musculoskeletal disorders can have significant consequences for dermatologists, impacting both their professional and personal lives.”

Studies and surveys often highlight Mohs surgeons, but the reality is that dermatologists who perform such procedures as laser therapy, cosmetic injections, soft tissue augmentation, liposuction, and hair transplantation also experience their share of MSDs. The increased use of dermoscopy and growth of teledermatology make dermatologists even more susceptible to MSDs.

“The common denominator is staying in awkward positions for long periods of time doing repetitive motions,” stated Ashish C. Bhatia, MD, FAAD, an associate professor of clinical dermatology in the dermatology department at Northwestern University Feinberg School of Medicine in Chicago.

“Before, MSDs were limited to proceduralists,” he added. “Now I’m seeing MSDs more often in general dermatologists.” Moreover, many dermatologists lack formal training on ergonomics, leading to improper work habits and postures, stated Tejesh Patel, MD, FAAD, professor and chair of the Kaplan-Amonette Department of Dermatology at the University of Tennessee Health Science Center in Memphis, Tennessee.

Impact on practice, career

“Musculoskeletal disorders can have significant consequences for dermatologists, impacting both their professional and personal lives,” Dr. Patel stated. “It’s the rule, not the exception, that surgeons in their seventies have crippling back or neck pain,” said Dr. Cook, who treats many Duke physicians. “I know a lot of uncomfortable colleagues, especially in my age group, who have had to cut their work volume because of MSD complaints,” he added.

“Musculoskeletal disorders eventually limit what you can do or how long you can work,” Dr. Bhatia said. When Dr. Bhatia began having muscle strains and neck soreness early in his career, he just took increasingly more ibuprofen to get through the pain. “When I talk to other dermatologists, they’ve done the same thing,” he said, noting that some peers developed tinnitus from taking too many non-steroidal anti-inflammatories.

Patrick K. Lee, MD, FAAD, professor and vice chair, and director of dermatologic surgery in the dermatology department at the University of California, Irvine, knows dermatologists who have taken a leave of absence because of their physical issues. Several colleagues have had surgery on their neck or lower back, forcing them to take even more time off for recovery.

Dr. Patel witnessed colleagues having to stop seeing patients in the middle of clinic and lay on the workroom floor until the pain subsided. Others have had to undergo physical therapy, therapeutic injection procedures, and surgery.

Worst case scenario, MSDs can cut a career short. “These injuries can be career ending, especially if a disc issue is not addressed, and you don’t seek help and correct the things that you’re doing that lead to MSDs,” said Dr. Bhatia, who has had two surgeries.

In addition, chronic pain and disability very often lead to reduced performance, Dr. Patel stated. “Dermatologists may struggle to maintain the same level of precision and quality in their procedures,” he said. Studies in laparoscopic operating room settings demonstrate that error rates increase when surgeons use a video monitor at an inappropriate height during minimally invasive surgery, Dr. Cook noted. Similarly, speed and quality of follicular unit extraction diminish over time when hair transplant surgeons “hunch over” to perform the procedure, according to a survey of hair transplant surgeons that Dr. Lee cited.

MSDs often begin early on

It’s not uncommon for residents and early-career dermatologists to experience MSDs. In both studies cited, MSDs presented early in the Mohs surgeons’ careers and continued throughout them. For James Ferrer, MD, chief resident in the Kaplan-Amonette Department of Dermatology at the University of Tennessee Health Science Center, lower back and neck pain started early in his residency.

Many residents at the end of rotation complain about pain and can be seen stretching in the hallway, Dr. Cook said, adding, “If a resident is having musculoskeletal pain, I try to address it before residency ends.” In a 2019 study, 44% of 243 medical students were interested in pursuing a surgical specialty. Following a surgical rotation, 75% reported musculoskeletal pain, and 36% changed to a medical specialty, noting that the “physical demands of the field” were a deterrent.

Dr. Cook believes that ergonomics should be a formal part of residency training. Former residents often contact him asking about his recommendations for tables, lighting, and other ergonomic tools.

Dr. Bhatia, who had his first surgery five years into practice, discusses ergonomics with his residents and fellows. “When you’re young, you feel like it won’t happen to you. But we do these motions repeatedly and it can happen faster than you think,” he said.

Dr. Patel is also concerned that dermatology residents aren’t educated about ergonomics or MSD prevention. “It would be beneficial for residents to receive training in ergonomics to prevent long-term injury and improve both practice longevity and job satisfaction,” he said.

Drs. Bhatia and Lee are hopeful that the physician well-being movement will elevate the importance of ergonomics.

Ergonomic solutions

Work-related MSDs can be prevented by using ergonomics, which OSHA defines as “fitting the job to the person.” Using ergonomically correct office equipment helps lessen muscle fatigue, increases productivity, and reduces the number and severity of work-related MSDs, according to OSHA. The following are examples of workplace equipment that has been found to be beneficial.

Exam table

Surgical tables should be adjustable to reduce strain from bending or leaning, Dr. Ferrer said. The biggest intervention that helped Dr. Cook was replacing his squared-off surgical table with a table that has a cut-out and narrow back. The cut-out table causes less strain on the thoracic and lumbar back than a square table and enables the dermatologist to access the patient more closely, particularly the face. “As a Mohs surgeon, that’s where I spend 95% of my day,” he said. Dr. Cook favors tables designed for otolaryngology and dental practices. His cervical pain disappeared within days after changing the table all those years ago. When Dr. Cook recently replaced his worn-out table, the new one was not ergonomically correct. Within days, his cervical pain returned, and he had to change the table.

Lighting

Adjustable, overhead lighting reduces eye strain and shadowing, Dr. Bhatia said. Dr. Lee prefers adjustable, ceiling-based lighting centered above the surgical table. Overhead lights with moveable arms allow the surgeon to hover over any part of the patient being worked on and identify certain areas to reduce shadowing. Dr. Cook controls the intensity and color of the lights in the operating room. He prefers yellow or glowing white light to neon white light, noting that too bright or reflective lighting causes squinting. Dr. Cook recommends using dual lights to illuminate the entire surgical field.

Exam chair

A chair with adjustable height and lumbar support helps maintain proper posture, Dr. Ferrer said. It helps if the chair can adjust in multiple directions, Dr. Lee added. A contoured chair works well for head and neck surgery because the surgeon can stand or sit next to the patient and even walk around the surgical site. The surgeon may benefit from using an adjustable stool, he said.

Surgical trays

Trays and tools should be positioned to minimize repetitive motions and awkward reaches, Dr. Ferrer said. Using wide-handled and lightweight instruments also reduces hand strain. Dr. Lee favors a height-adjustable mayo stand.

Surgical magnification eyewear

Devices, such as surgical loupes and dermatoscopes, promote neutral neck positions and reduce flexion, Dr. Ferrer said. Magnification devices can reduce eye strain, headaches, and musculoskeletal injuries. After his neck surgery, Dr. Bhatia bought expensive customized loupes that keep him in the right plane. Dr. Cook, however, believes that loupes worsen cervical pain because they force the wearer to move their neck back and forth to find the focal point and stay in focus.

Microscopes

Microscopes should be adjustable to maintain an ergonomic posture. Dr. Bhatia’s microscope is on an adjustable-height table. With various people using it, they can simply adjust the table to a height that is comfortable for them.

Computer workstations

The computer screen should be at eye level to reduce neck strain, Dr. Ferrer said. An ergonomic mouse and keyboard, which should be at arm’s length, are designed to reduce strain on the wrists, fingers, and forearms, helping to prevent repetitive strain injuries. Like the microscopes, Dr. Bhatia’s computer workstations are on adjustable-height tables. Proper chair height and headset use can reduce strain, as well.

It’s not an adjustment in equipment, but scheduling is a workplace adjustment that can help reduce MSDs. A heavy workload increases the risk of MSDs, Dr. Ferrer said. Dr. Cook recommends spreading out procedures to vary the type of tasks being performed daily. “If you do one-and-a-half days of procedures a week, don’t do them all on Monday and Tuesday morning,” he said.

Posture and positioning

What does good posture look like? To Dr. Lee, the hips are forward, shoulders are back, chin is tucked, and the head positioned over the rest of the body. “When I was growing up, people advocated balancing a book on your head as you walked to develop good posture,” he said. Dr. Lee, who is also director of the Micrographic Surgery and Dermatologic Oncology Fellowship at UC Irvine, tells trainees to imagine that they have a book on their head as they start to do a procedure. If they lean over, the book will fall on the patient.

Dr. Bhatia is always correcting trainees’ postures or anyone with whom he works, for that matter. Sitting during certain procedures to break up his routine has made a big difference.

Other tips Dr. Ferrer has found helpful are keeping the neck in a neutral position with flexion no greater than 15 degrees, avoiding prolonged static abduction and flexion of the upper arms, and regularly changing positions to avoid excessive strain on one part of the body.

The patient’s position is just as important as the dermatologist’s. Positioning patients close to the edge of the exam table minimizes forward bending and leaning, Dr. Ferrer noted. Dr. Cook describes his routine for performing Mohs surgery as being very regimented. “I’m always on the right side of the patient. The patients are placed in the same position, including elevation, because I figured out what works for me from a comfort perspective,” he said.

Stress management

A wellness program that includes regular short breaks and stretches combined with certain exercises and ergonomic tools can reduce pain and prevent MSDs.

“Dermatologists who take breaks every 15-20 minutes to stretch can experience reduced pain, improve physical performance, and enhance focus,” Dr. Patel said. Micro-breaks from one-and-a-half to two minutes, combined with targeted stretching, help alleviate tension, especially in the neck and back, without affecting overall procedure duration, he added. Surgeons who took stretching micro-breaks had less post-procedure pain in the neck, back, shoulders, wrists/hands, knees, and ankles, according to a 2017 study. They also perceived improvements in their physical performance and mental focus. Dr. Lee encourages physicians to take 15-minute breaks, noting that unionized staff at health care institutions have built-in breaks. Dr. Bhatia is a fan of micro-breaks for stretching.

“Dermatologists who take breaks every 15-20 minutes to stretch can experience reduced pain, improve physical performance, and enhance focus.”

Keeping the abdominal core strong is essential for maintaining good posture. “If you only have time to do one exercise, do core exercises,” Dr. Lee stated. Dr. Bhatia does a set of core exercises and stretches regularly. If he can’t go to the gym, he can do them at home or in the office. “Something as simple as keeping your core tight will cause you to fatigue less and have less pain,” Dr. Bhatia said. In addition to core exercises, Dr. Patel recommends doing planks to strengthen core muscles and maintain spinal alignment, scapular retraction to strengthen the upper back and shoulders, and rotator cuff strengthening and cervical stabilization exercises with resistance bands to help build muscle endurance and prevent strain during procedures.

Several tools can be helpful in relieving stress and preventing MSDs. OSHA recommends anti-fatigue mats for people who stand on their feet more than two hours a day as the mats reduce strain on the legs and lower back. “The thicker the mat, the better,” said Dr. Cook, who also recommends shock-absorbing insoles. They reduce pressure on the feet and joints and minimize the risk of injury. Compression socks promote circulation and reduce leg fatigue. They should offer medium compression (20-30 mmHg), said Dr. Cook, who insists that all his residents wear them. He also wears a compression t-shirt under his scrubs that supports his back and pulls his shoulders back. The t-shirt has dramatically helped relieve his back pain. Other tools include foam rollers, lumbar support cushions, and therapeutic massage balls.

Seeking professional advice

Dermatologists experiencing MSDs should consider contacting a physical or occupational therapist, certified ergonomist, or physiatrist.

Dr. Cook had an ergonomically trained occupational therapist observe him for hours on the job, evaluate the practice set-up, and recommend improvements. “It’s 26 years later and I’m still practicing,” he said. Most academic centers, and even community hospitals, have occupational therapists on staff who can do an ergonomic evaluation, Dr. Cook noted.

Dr. Lee had a colleague who once had an ergonomist do an evaluation of their office and Mohs lab. Despite failing the evaluation because so much was ergonomically incorrect, his colleague implemented many improvements to optimize posture and reduce strain.

Dr. Bhatia recommended contacting a physical medicine and rehabilitation physician who can do an evaluation and either prescribe physical therapy or exercises or determine if surgery is needed.

Practicing good ergonomic habits and being mindful of one’s position at the bedside, microscope, and computer can help prevent MSDs. “Minimal changes promote rapid and effective improvement,” Dr. Cook stated. Dr. Bhatia agreed. “Any incremental change you make will be worth it in the long run,” he said. “Everybody wants to have a long, productive, and healthy career,” Dr. Lee concluded. “Ergonomics is a low-hanging fruit to obtain good habits that will help sustain your longevity.”

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