Adding Insult to Injury
How Poor Operating Room Design is Hurting our Bodies and Careers
The Boeing B-17 fighter jet was the crown jewel of the United States Air Force in the Second World War - or at least, it was supposed to be. Despite its remarkable performance in combat, the plane suffered over a thousand crashes during routine landings, which were initially attributed to “pilot error”. Training modules aimed at educating pilots proved ineffective and forced the flight engineers to look more critically at the process of landing. A thorough investigation ultimately revealed a simple design flaw at the center of the crashes. The controls for two different operations - lowering landing gear and pulling wing flaps - were identical. In both routine and more urgent circumstances, pilots would reach for one control, meaning to reach for the other. This insight prompted a redesign of the instrument panel with distinct controls that prevented this misperception and eliminated the problem. The process of discovering design flaws inherent to the B-17 not only ushered in the ascendancy of the U.S. Air Force but also gave way to the new field of human factors design - the idea that systems, not people - were responsible for errors and inefficiency, and could thus be modified to keep humans safe.
In an operating room 87 years later, I, too, found myself fumbling with the instruments in my hands. We were in the middle of a laparoscopic inguinal hernia repair - a minimally invasive operation in which long instruments are placed through keyhole incisions to repair a hole in the abdominal wall through which internal organs extrude. A key step of the operation is to use a long instrument called a tacker to fire small thumb tacks into a mesh to affix it to the abdominal wall around the hole, effectively covering it up. As usual, I was struggling to use the tacker - I could stabilize the instrument in my hand or fire it with my fingers, but it seemed that I could not do both. Normally, this lack of finesse would earn a sharp rebuke. But on this day, the attending (with whom I was operating for the first time) pointed out how horribly mismatched the bulky instrument handle was for my extra small glove sized hands.
This realization led to similar findings in other operations. An hour of dissecting, dividing, and reconnecting vessels while wearing magnification loupes was routinely followed by an afternoon of neck pain. No number of step stools seemed to put me at the correct height to operate comfortably. A string of gallbladder operations during which I was tasked with pushing a 60cc syringe of contrast through a 1mm wide cholangiocatheter left me with golfer’s elbow. In speaking with my peers, I heard my concerns echoed in their experiences. “How am I going to do this procedure for 8 more weeks?” and “I need a back transplant” were all too common refrains. What I had previously written off as the growing pains of surgical training now appeared to be flaws in the designs and processes of surgery itself. Such were my informal introductions to the field of human factors design and its corollary discipline of ergonomics.
While both of these named disciplines originated during the Industrial Revolution and gained prominence in the WWII era, the concepts have existed since Antiquity - even within the field of surgery. Hippocrates described lessons on posture, positioning, and instrument handling over two thousand years ago:
“The most appropriate posture for the surgeon is to be seated, with his knees at a right angle and close together. The knees must be a little higher than the bubonic area and slightly apart, so that the elbows can be propped on them or spread wider than the thighs…[instruments] may not impede the work, and there may be no difficulty in taking hold of them…”
The clinical and technical advancements in surgery - not only since the time of Hippocrates, but in the last few decades alone - have outpaced similar advancements in ergonomics. While the last century saw the advent of sterile technique and minimally invasive surgery, surgeons are in as much pain as ever. Innovations in robotic surgery have made tremendous strides to improve surgeon comfort and patient outcomes, but even this modality is not immune to its own profile of ergonomic risks, spanning from hand and finger symptoms to neck pain. Furthermore, the robotic platform’s applications remain limited to a small but growing number of operations at this time.
Regardless of the operating platform used, surgeons have to continually adapt to an environment that was not built for them, operating for hours in uncomfortable positions and performing repetitive movements with poorly designed instruments. As a result, our workforce sustains high levels of musculoskeletal strain, with 87% of surgeons reporting work related pain, 15% requiring surgery to treat related injuries, and an estimated 15% retiring early. All of this amounts to tremendous personal and systemic cost, much of which is not yet quantified and understood fully. There are no established avenues for reporting work related injuries for surgeons, and even if there were, fear of retribution fosters a culture in which surgeons opt to work through their pain. There are no claims databases that filter by surgical occupation, and so the true cost of poor workplace ergonomics remains nebulous. While many of these effects are felt down the line in lost work years and treatment costs, their roots take hold in training.
Residents enter surgical training with an understanding that not only are they embarking on a grueling journey, but also that they must quietly tolerate the discomforts along the way. It is unclear what historical truths this culture stems from, but one could look to the model of surgical residency first pioneered by William Halsted at Johns Hopkins Hospital at the turn of the twentieth century. This era was marked by dedication to the craft at high personal cost - for all his contributions to surgery, Halsted himself suffered from a severe opioid addiction that rattled his life and career. Furthermore, the pyramidal structure of residency that he established fostered a cutthroat environment in which only those with nothing left to sacrifice would be privileged enough to advance. Since Halsted’s time, notable transformations have brought surgical training to the modern era, such as adopting the rectangular residency structure and, more recently, the institution of duty hours. Still, a tacit culture of hierarchy, personal sacrifice, and adherence to the status quo remains. Even as the days of the toxic surgeon are fading out, trainees are largely reticent when expressing their basic needs (sleep, food, and physical well-being).
Our field is now catching up to its realities, though, and conversation is moving towards honest, solutions-oriented discussions. This is evidenced by the growing body of literature dedicated to topics such as wellness and surgical ergonomics. In fact, publications on surgical ergonomics have skyrocketed from 34 in 1990 to 662 in 2020, and new forums for this topic in academic surgery have emerged. In 2021, Dr. Geeta Lal, an endocrine surgeon at the University of Iowa, founded The Society of Surgical Ergonomics after seeing her own experiences with pain and injury mirrored in so many of her colleagues. In the Society’s inaugural conference, 26 researchers presented on topics ranging from educational workshops to exosuits. One of the keynote speakers was Dr. Susan Hallbeck, a human factors researcher from the Mayo Clinic, who presented their group’s seminal work on microbreaks. Their work showed that incorporating microbreaks into cases is an effective strategy to combat the sustained physical stress of operating for hours. That this strategy is effective should come with no surprise - it borrows from fundamental principles of workplace ergonomics that have been established for years in other industries. Its low cost, low tech approach makes it attractive to implement at any institution.
While introducing microbreaks during cases is a promising start, it still puts the onus of harm prevention on the surgeons themselves. To truly revolutionize our practice to be safer and more amenable to a diversifying workforce, we should seek out solutions that restructure our environment and eliminate hazards in the first place. This framework for harm reduction, termed the hierarchy of controls, has been adopted by the National Institute for Occupational Health and Safety (NIOSH), the government agency overseeing workplace safety and health. It describes five levels of interventions aimed at reducing workplace hazards. Interventions aimed at the higher controls that eliminate the hazards (including innovations such as robotic surgery) will produce more substantial risk reduction compared to lower controls that target the individual worker (such as behavioral changes).
The long game is redesigning everything. In the meantime, there are practical, albeit imperfect, solutions that we can implement to ease the burden of ergonomic stress.
First, we must measure our pain. While survey based studies describe this problem at a point in time, we must continuously measure our ergonomic stress and risk of injury to make meaningful changes. This is mostly done with surveys today, but new technologies that assess motion (such as video analysis, accelerometers, or inertial measurement units) and directly quantify muscle strain (such as electromyography) are being tested. These data can serve as the basis for guiding interventions, tracking their effectiveness with scientific rigor, and ensuring transparency to incentivize systems to invest in their workers.
Next, team leaders (such as the operating surgeon or the circulating nurse) can propose an ergonomic time-out, both at the beginning of the case and throughout, to allow the team to reevaluate and address ergonomic issues in real time. These adjustments can include repositioning monitor screens, requesting equipment such as step stools or anti-fatigue mats, or even rotating labor intensive roles, such as retracting, to offer respite to the most at-risk members of the team, such as medical students and junior residents.
Lastly, we can democratize the design process itself and give every surgeon and trainee the opportunity to collaborate with engineers and human factors scientists. Surgeons and trainees are best poised to identify pain points and potential solutions, and we should use our own expertise to effect change. Much as we invite industry sales representatives into our operating rooms, we can and should invite the engineers who make our instruments to observe and interview us. In this way, we can close the chasm between the people who design instruments and the people who use them every day.
Surgeon and ergonomics are derived from the same etymological root, ergon, the Greek word for “work”. While the fields of surgery and ergonomics should go hand in hand, they have instead evolved to be at odds with one another. Many of the short and long term solutions to bring them back in alignment will take time, resources, and perhaps most valuable, buy-in from leadership. However, the stakes are too high to relegate this issue to the backburner. With a looming surgeon shortage, astronomical burnout, and increasing rate of injury and early retirement plaguing our workforce, protecting surgeon health and wellbeing will be instrumental in recruiting and retaining the best and the brightest. Recognizing this notion will unlock the next century of innovation in surgery.
I would like to acknowledge my friend and coresident, Tejas Sathe, without whom this article would not have made it from idea to paper.
Additional Readings:
https://medium.com/swlh/the-flying-fortress-fatal-flaw-694523359eb
http://ergou.simor.ntua.gr/research/ancientGreece/AncientGreece.htm
Prevalence of Work-Related Musculoskeletal Disorders Among Surgeons and Interventionalists: A Systematic Review and Meta-analysis
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856533/#r18-1
https://www.societyofsurgicalergonomics.org/
https://pubmed.ncbi.nlm.nih.gov/28059962/
https://www.cdc.gov/niosh/topics/hierarchy/default.html
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Dr. Meghal Shah is a General Surgery resident at Columbia passionate about global health and human rights
The opinions expressed in the article are not affiliated with any institution, company or product. The article should not be interpreted as medical advice.
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