Imagine a physically demanding job, one that requires a person to perform repetitive motions again and again over the course of the day, the week and throughout their careers. An endoscopist might not be the first occupation that comes to mind when considering what positions might be at risk for work-related pain or injuries, but increasing pressure to improve efficiency and treat more patients comes with the side effect of higher risk for repetitive use injuries among gastroenterologists.
Ergonomics has been discussed in endoscopy for decades, but according to Amandeep Shergill, MD, MS, associate clinical professor of medicine at the University of California San Francisco and director of endoscopy at the San Francisco VA Medical Center, it emerged as a hot topic within the last 5 years, becoming the focus of various professional societies, including the ASGE, the ACG and the AGA.
“There’s so much that we don’t understand about what a reasonable workload for physicians is,” Shergill told Healio Gastroenterology and Liver Disease. “Endoscopy days are all about efficiency. It’s about turning over rooms and doing more procedures than ever before. What’s actually best for the physician? We don’t know the answer.”
The Scope of the Problem
Survey-based studies have estimated that between 39% and 89% of gastroenterologists have experienced injuries related to endoscopy. In a case-control study that compared gastroenterologists with nonprocedure-oriented specialists at the Mayo Clinic, researchers found that the incidence of musculoskeletal injury was high among the GI group (74%) compared with the non-GI group (35%).
Risk factors for endoscopy-related pain include higher procedure volume, longer hours performing procedures and total number of years spent performing endoscopy.
As the population ages, Patrick Young, MD, professor of medicine at Uniformed Service University in Bethesda, Md., said gastroenterologists have been tasked with doing more to meet the demand for more procedures, including more screening colonoscopies.
“We’re doing more procedures than we did 20 years ago,” he said in an interview. “Physicians tend to get into it because they’re a little bit altruistic, and they’re focused on their patients. They don’t focus so much on their own health and the consequences their work may have on them.”
The typical areas where physicians can experience endoscopy-related pain can be found all over the body, including the neck, shoulders, knees and hands. The pains can stem from several areas throughout an endoscopy suite, from the positioning of the bed and monitor to how and where a physician stands during a procedure.
“People get neck and back problems just from the way they stand,” Young said. “You could be turning your head to look at a monitor that isn’t placed so well. … You can get neck arthritis. I’ve known people who have even had to get neck surgery.”
A lot of the injuries come down to how an endoscopist holds and operates the scope. They have to hold it while they manipulate the dials with one hand and maneuver the insertion tube with the other. Repetitive, high force exposures can lead to upper extremity musculoskeletal disorders, including, carpal tunnel syndrome and tendonitis. The repetitive motion of moving the scope’s dial can cause swelling in the tendons of the thumb known as De Quervain’s tenosynovitis. It is so common among gastroenterologists that it has earned a nickname.
“Some people call it ‘endoscopist’s thumb,’” Young said.
Although it is more common among more experienced physicians, endoscopy-related pain or injuries can occur at any point in a career.
“When I was in fellowship, one of the fellows a year ahead me left endoscopy because she felt like it was too hard on her body, and she wasn’t ever going to be able to become a successful endoscopist,” Shergill said. “She was one of the smartest people I knew, and she went into radiology. I thought, ‘Wow. What does she know that I don’t?’ You just need to take one look at the endoscope, and it is clear that there is a design problem.”
There are a few things that practices can implement to reduce some of the risk factors for endoscopy-related pain and injuries.
“Flexibility is key,” Young said. “Equipment should be adjustable. In our endo unit, the endoscopists’ heights range from five-foot-two to six-foot-five. One height isn’t going to work for everybody. You need to be able to adjust monitor height and monitor position, move it left to right.”
Studies in surgery have shown that the monitor should be just below eye level directly in front of the bed to allow physicians to view it without craning or turning their necks during procedures. The position of the examination table also needs to be optimized so that it sits at or just below elbow level. Both features also need to be adjustable to accommodate the 5th percentile female and 95th percentile male in terms of height to account for endoscopists of all shapes and sizes.
“That can potentially be difficult, especially for administration,” she said. “But what we see is that they have a heavy patient load on certain days and other days where they don’t. Making it a bit more spread out over the course of the day, as well as over the work week, would go a long way in helping people recover from the workload they’re exposed to.”
These breaks would give endoscopists a chance to stretch out their overworked muscles of the shoulders, hands, legs and neck.
“While there’s no clinical trials showing it in endoscopy in particular, there’s a lot of data looking at other repetitive motions that show that it’s going to help out,” Young said, adding that taking care to recognize how you stand can also be important.
“The other thing is empowering people to give you feedback,” Young said. “You’re so focused on the screen and what you’re doing therapeutically, you don’t notice that you end up in an odd position. You can inform your nurses and your techs, ‘Here is the way I want to be standing. If you see me doing something different, please let me know so I can correct that.’”
The Problem of the Scope
Even if there are steps an endoscopist can take to maintain their flexibility and reduce the impact of their workload, Harris said the root of the problem must be addressed before she expects to see any real change.
“We really need to address the exposures before any stretch program or therapy program is useful,” she said.
The root of the problem is the scope itself, the experts agreed.
“The basic design of the control section and insertion tube have not significantly changed since the 1980s,” Shergill said. “When you think about what’s happened with cars, and phones, and everything else that we use, it is pretty mindboggling that there hasn’t been that same innovation in the field of endoscopes.”
Although endoscopes are generally one-size-fits-all devices, their users come in all different sizes. Shergill said she is five-foot-two, a foot shorter or more than some of her colleagues and wears a small size glove. Despite drastic differences in size, all endoscopists use the same scopes simply because that is all that is available.
“Hand sizes can be quite different,” she said. “[The scope] might actually be too small for a large man, and it’s too big for me. We don’t have the ability to customize anything about the endoscope.”
In one survey of endoscopy in fellows, 41% reported that they thought their hand size was too small for endoscopes, and many thought their hand size impacted their ability to learn (78%) and perform endoscopy (62%).
“The poor fit results in poor biomechanics. Endoscopes are not made for the breadth of users who are using the scopes,” Shergill said.
In addition to their size, Young said the shape of scopes can also be a problem, forcing users to exert pressure on the fingers in the left hand to move the dials as they perform a procedure.
“They’ve been this way for a long time,” he said. “If you were going from scratch and gave a high school student a project to make a scope to navigate the colon, they would not design the scope we currently have.”
Young said the scopes of the future might include an electromechanical assist to help cut back on the human force needed to operate them. While newer scopes — like the Aer-O-Scope (GIView), which helps cut down on some of the torque forces that come with manual insertion of traditional endoscopes — are in development, nothing has been approved by the FDA.
Slow progress on scopes might come down to gastroenterologists themselves. Shergill said physicians can be closed minded when it comes to adopting new technology.
“I’ve talked with companies who have tried to reinvent the scope and have come up with some really good ideas and products that might address some of these biomechanical issues that we have identified with current scope design. Physicians take one look at a new design, though, and will often say ‘I don’t want to scope with that,’” she said. “They can imagine retraining on a new instrument and are unwilling to sacrifice, even in the short term, any efficiencies despite the possibility of longer-term gain. In many ways we’re our own worst enemy.”
New endoscope developments might be on the horizon, but adjunct accessories might offer physicians something else they can use now to make their jobs easier. Harris and Shergill’s group have previously explored a zero-gravity arm that helps offset some of the workload during a procedure. Although the arm displayed some benefit, ultimately, it had some usability issues.
“There has to be two stages,” Harris said. “You design something that is effective and reduces exposure. Then there’s a whole other step in making sure its efficacious and people will actually use it. A new design can’t drastically disturb how endoscopists scope.”
One of the UC Ergonomics Program’s more recent studies is a Pentax-designed stand that holds the scope during procedures.
“Instead of someone having to hold the scope during the procedure, they can rest the scope on the stand and still maneuver the dials but not have to support the weight of the scope,” Harris said. “If you place it in the stand for the entire procedure or even half the procedure, it may eliminate a lot of the work load.”
The Future of Ergonomics Research
Finding interventions or exercises that help with the pains and injuries gastroenterologists experience has been difficult because of a lack of research. Although the topic has been explored in numerous studies, they have all been small or survey-based.
Young said he has heard anecdotally that more physicians are taking precautions to limit injuries and pain. Some have even told him it is working.
“This isn’t something that happens overnight,” Young said. “If you implement something 2 or 3 months ago, you might feel better, but telling if you’ve prevented an injury? That’s difficult without larger studies looking at a bigger group over time.”
Shergill, Harris and the researchers at the UC Ergonomics research team have been working to collect data on biomechanical measurements like force and wrist postures associated with endoscopy, which they hope to publish soon.
“First, we need to understand the biomechanical risk factors associated with performing endoscopy, and which subtasks are associated with greatest risk,” Shergill said. “Then, we need a dialogue with the scope companies so that they can better understand how the current endoscope design results in high-risk exposures to endoscopists, and we need to push them to make changes to mitigate these risks, for the sake of the endoscopists who are using them.” – by Alex Young
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