I Used to Be a Surgeon

Staff Safety

By: Joe Paone

Published: 4/16/2020

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Increased awareness about ergonomics in the OR will help prevent career-ending injuries.


Kenneth Levin, MD, was performing his fourth big abdominal case of the day when his neck and back suddenly froze. "The PA looked at me, and I looked at her, and she knew instantly I was in big trouble," he recalls. "I had a whole roomful of people watching me just standing there, paralyzed."

After a couple minutes, Dr. Levin regained some mobility and finished the case. Retirement entered his mind. "But I didn't want to do that," he says. "I loved operating. I was good at it, and things had been going so well. So I pushed myself." Less than a year later, though, he reluctantly performed his final surgery. "It was difficult," he recalls. "I thought I was at my prime, and it turned out my body couldn't keep up."

Dr. Levin practiced general and colorectal surgery in Madison, Wis., from 1991 until 2013, when, in his mid-fifties, he performed that last case. Like many surgeons his age, he wasn't educated about the detrimental health effects surgery could bring. Still, he was always keen to stay fit. "I did a lot of core exercises every day, and my lower back is perfect," he says. "But I never even considered [an injury to] the neck until all of a sudden, there it was."

He then paid more attention to table positioning, tried to avoid prolonged awkward positions, operated more slowly when possible and took microbreaks to stretch or pause. Although often "any extra time seemed a luxury, so you just pushed through [the pain]," he says. "It seemed like in order to keep your income relatively steady as time went on, you had to do more and more cases."

In 2004, Dr. Levin developed two herniated discs in his neck from degenerative overuse. He blames it on the rigors of operating. "The twisting and bending and contorting, trying to see things in the pelvis, caused a lot of strain and abuse on my spine," he says.

Dr. Levin then experienced pain in his left arm and suffered two more herniated discs, with one causing nerve pressure. Physical therapy and medications mitigated that pain. "Then one day I did three very prolonged, difficult operations, three or four hours apiece," he says. "I remember struggling, and I was pretty tired afterward." He awoke the next morning to "unbelievably intense, incapacitating pain" in his right arm, which required immediate surgery.

Three months later, he was back at work, but soon experienced pain in his left shoulder, which revealed more disc issues along with nerve impingement. Reluctant to go under the knife again, he reduced his caseload and scheduled more outpatient cases. But the pain remained, and Dr. Levin devoted more time to training and educating another surgeon. "I thought, 'I'm probably not going to be working here forever, so why not teach somebody the things I know?'" he says.

When a colleague went on disability due to hip problems, Dr. Levin further assessed his career's pending mortality. "I saw there was an option to go on medical disability and bow out gracefully," he says.

Dr. Levin's career had a joyful epilogue. A few times a year, he'd assist on cases, which he found mentally satisfying. In 2016, he was asked to work for three to six months as an operating room first assistant.

"I didn't want to put in too many hours, and I didn't want to get hurt again," says Dr. Levin. He agreed to work two half-days a week, but the supposedly temporary assignment ended up lasting three-and-a-half years. "I loved it," says Dr. Levin. "I didn't have to maintain total stationary focus and didn't have the constraints I had as a primary surgeon. I really enjoyed it and didn't have any neck problems doing any of it."

Abused and neglected

Peter Nichol, MD, PhD, a pediatric surgeon at UW Health American Family Children's Hospital in Madison, Wis., said in a 2012 American College of Surgeons article, "Our bodies have been abused and neglected." Eight years later, he reports, the situation hasn't changed much.

He knows several surgeons in rough physical shape, reciting a litany of hip replacements and neck operations. "A lot of us are breaking down. There's a culture among surgeons that we're going to gut it out and be tough," he says, reminiscing about the "hair on fire" environment he experienced during his residency. "You were expected to suffer to become a surgeon." When residents graduate to their own practices, many expect their stress and pain to decrease, but for many, it just gets progressively worse, he adds.

COMFORT MEASURES
Simple Solutions Improve Surgeon Comfort
BODILY HARM Laparoscopy is often positioned as an ergonomic upgrade for surgeons, but its techniques and tools present their own potential for pain.

Do you know how your surgeons really feel after another long day in the OR? Many hide intense physical pain from enduring countless surgeries — until one day, they can no longer perform surgery. Marissa Pentico, MS, OT/L, CPE, wants that to change. As ergonomics coordinator at Duke University's Occupational & Environmental Safety Office in Durham, N.C., she spends an inordinate amount of time researching surgeon comfort. She says surgical administrators have numerous options available to reduce surgeons' ergonomic risk factors, including work-practice modifications that require minimal or zero financial investment. Some tips from Ms. Pentico:

  • Adjustable equipment to reduce awkward positions. That goes for the stool, surgical microscopes and other equipment that is used for prolonged periods. Add surgeons' preferred settings to preference cards so equipment is properly set up before surgery.
  • Alternating procedures. Holding an awkward position for a long time can place tremendous strain on the body. Is it feasible for surgeons to perform procedures equally well sitting and/or standing? If so, they should toggle between the two whenever possible during lengthier surgeries.
  • Platforms with rails. Risers are often used by shorter surgeons in ORs, but surgeons have been injured falling from them. Ms. Pentico recommends using wide platforms with rails. You'll want to consult infection control, however, because the rails could be in the sterile field.
  • Better-fitting instruments. When an instrument doesn't fit right, surgeons often contort themselves to correct for the ergonomic deficiency, which can lead to injury. Look not only for better fit, but other ergonomic features, too. "Some laparoscopic tools now articulate, so the surgeon doesn't need to bend into awkward positions," says Ms. Pentico. "The scope does most of the bending for them."
  • Improved positioning. The patient should be as close to the surgeon as possible, with the table height adjusted and tilted as needed. Balance access and comfort as well as you can.
  • Two surgeons, one case. Alternating with the resident allows the attending and resident to separately take breaks or mini-pauses.
  • Equipment holders. Surgeons often hold equipment for long periods. Can you provide holders for equipment so they can release their grasp without putting the equipment down?
  • Modified culture. Microbreaks as short as 30 seconds and stretch breaks can improve surgeon focus and comfort, but may not normally be practiced. This would require the support of the attending and administrators. The first step toward establishing an ergonomic program for surgeons is education on risk factors they face and initiating basic modifications that can be immediately implemented. The role of the administrators is crucial in this.

While the time-honored belief was that pain was the price you paid to be a great surgeon, a growing number of surgeons now question that no-holds-barred work ethic. As the pool of younger surgeons grows, they'll likely bring their cases to ORs outfitted to address their ergonomic concerns.

— Joe Paone

Dr. Nichol scales 100 flights of stairs a day. He practices yoga. He gets physical therapy for his right hip, neck and lower back. Still, his legs ache after every day of surgery. His right hip hurts, too. "I don't know what's wrong with it," he says. "It's been bugging me for eight years. When I was younger, I could ignore the pain while I was operating. Now it's getting harder and harder to do that."

He talks about extending careers as an athlete would, noting how LeBron James devotes a significant chunk of his earnings to maintain his body. He believes surgeons should approach their musculoskeletal health similarly.

"We've got to train, eat and think like athletes. It's a physical thing we're doing. I'm only 52 years old and I train. I'm working on my legs, back, shoulders and neck to keep them strong. And I'm still having physical problems."

Surgical facilities should take a long-term view of their talent, says Dr. Nichol. His surgical department implemented a wellness program for surgeons. "Attitudes among surgical leadership are starting to change," says Dr. Nichol. "They want to know how to keep surgeons productive for the next 40 years, rather than having them burn out and break down after 20 years."

Dr. Nichol believes medical equipment companies must focus more on addressing ergonomics in their product designs. Take surgical staplers.

"They're built for people with [size] seven-and-a-half hands," he says. "Our female surgeons have to grab the stapler and fire it with two hands."

Mechanically inclined OR staffers such as nursing assistants and surgical techs could generate significant product ideas, according to Dr. Nichol. "They watch surgery day in and day out, and a number will come up with seemingly crazy ideas that actually could be great solutions," he says. "But those people have no way to interact meaningfully with manufacturers."

Dr. Nichol envisions summits that match vendors with product development opportunities based on ideas generated in ORs. He says, "If you could develop something where ideas can be harvested, where people who come up with the ideas get credit for them and are participants in the process and get a piece of the financial pie, a company could come up with a solution that's applicable across all facilities." OSM

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