Excess physical and cognitive work load, poor work/life balance, and pain/fatigue lead to work-related injury and burnout.1–8 Work-related pain is present in up to 87% of surgeons8 and burnout is reported in up to 40%.9 Both have been implicated as potential patient safety hazards.10 With the increasing complexities of operative procedures and the current climate of surgical practice, surgeons are at a greater risk of work-related injury and burnout than ever before. Surgeons increasingly find themselves with a growing workload and little prospect of relief. A most important factor in the shortening of surgeon career longevity is work-related pain.1–8 Efforts to elucidate evidence-based solutions have met with limited success and produced a paltry arsenal to combat this growing pandemic among surgeons.
There is little doubt that the practice of surgery has evolved its provision of patient benefits through minimally invasive surgery (MIS).11 Practitioners performing MIS cases on a regular basis will be subject, however, to deleterious ergonomic risks irrespective of age, experience, gender, height, or handedness.8 The physical stresses of performing MIS stem from a lack of direct visual or physical access to target anatomy, reduction in degrees of freedom, the fulcrum effect, and poorly designed tools, all creating awkward working postures and a limiting 2-dimensional view of the operative field.8
The amplified physical and cognitive workload of MIS and its associated injuries has been well characterized in numerous studies.8,12–17 Common approaches to counter the physical and cognitive challenges of surgery have arisen through the study and proposed implementation of ergonomic practices demonstrated to reduce fatigue, strain, and injury. To date, these have had a little impact on a surgeon-perpetuated culture that fosters self-sacrifice in the care of patients while facing indifferently the possibilities of injury to the surgeon.18
Recent efforts in the field have shed light on ergonomic strategies to mitigate pain, during both open and MIS. One of the earliest ergonomic studies focused on the discipline of surgery was conducted by Berguer et al19 to assess motion in the axial skeleton of surgeons during MIS vs open surgery. Head and back positions (normal, bent, twisted) were identified and analyzed during live surgeries as well as simulated exercises. The authors reported surgeons’ head, neck, and axial spine to be in a more erect, static position during laparoscopic procedures than open procedures. Moreover, participants exhibited a forward shifted center of gravity during performance of MIS. Their study concluded that the ramifications of such static posture and forward center of gravity in the performance of MIS can translate to immediate musculoskeletal strain, compromised task performance, and potential chronic injury.
Throughout these studies, physical interventions—in the form of regular breaks to disrupt static postures, improve physical function, and maintain mental focus—have been proposed as potential means to protect surgeons and patients. The implementation of mandatory breaks to counter fatigue, reduce errors, and ensure safety has been a valuable strategy employed in many demanding fields, including air traffic control, simultaneous interpretation, computer science, and professional mountain climbing.20–22 Only a few such studies on the impact of intraoperative pauses for the sake solely of rest and refocusing the surgeon and surgical team have been published.18
Our effort then has been concentrated on increasing knowledge regarding how implementation of imposed breaks affects work-related pain and mental focus for surgeons. We developed standardized “targeted” stretching micro breaks (TSMBs) and conducted a multicenter intervention to study their impact. Our study aims were to (1) quantify the physical strains posed during practice of open and MIS while characterizing their impact on the professional and personal lives of surgical practitioners, and (2) determine how micro breaks with stretch exercises affected pain, physical function, and mental focus of surgeons performing procedures.
This institutional review board-approved, prospective multicenter study was held at 4 sites: Anne Arundel Medical Center, Annapolis, MD; Mayo Clinic Rochester, Rochester, MN; Carolinas Medical Center, Charlotte, NC; and University of Louisville Medical Center, Louisville, KY. The 66 participants were academic and private practice surgeons, surgical trainees (fellows and residents), or surgical assistants (physician assistants and nurse assistants). A 1-sequence crossover study design was used. Surgeons participated for 1 day without the intervention and then 1 day with. There was approximately a week between measurements.
To prevent operative flow disruptions, maintain patient safety, and maximize surgeon participation, data were collected at 4 different time points: baseline, including demographics before any operative day; during an operative day without intervention (control); followed by an operative day with intervention; and at the conclusion of the TSMB study (see Figure, Supplemental Digital Content 1, https://links.lww.com/SLA/A978, which illustrates our enrollment process).
Participant demographic data were collected by members of the research team regarding gender, age, height, weight, hand dominance, exercise habits, specialty, and the 3 procedures most commonly performed by each participant. Operative volume was assessed by years of experience, mean operative days per week, and mean number of cases per operative day.
Baseline assessment quantified pain associated with surgical practice and its impact on professional and personal lives. Details were elicited on physical discomfort after performing surgery; length of time between start of surgery and start of pain; duration of pain; and affected musculoskeletal regions (eg, neck, shoulders, upper back) in order of severity. Practitioners were asked to rank strategies used to counter pain from the following options: changing position, taking a break, adjusting the surgical field, using a step stool to adjust height, changing instruments, getting treatment, taking time off operating, ignoring it, or other.
Additional questions focused on the impact of pain on posture, visualization, balance, mobility, concentration, reaching for objects, lost work days, stamina as well as worst pain experienced in the last 24 hours and whether it interfered with sleep and personal relationships. Finally, practitioners were asked whether they were concerned their pain would limit their ability to perform surgery in the future. Each participant rated pain/fatigue, physical and mental performance, and task load using surveys based on the validated Nordic Musculoskeletal23 questionnaire, the National Aeronautics and Space Administration Task Load Index (NASA-TLX),24 and the Surgery Task Load Index (SURG-TLX)25 during 2 operative days, 1 during which they implemented TSMBs and the other in which they did not. Case type and duration were recorded as were surgeon pain data before and after each procedure and at the end of the surgical day. Individual body part pre/postdiscomfort difference was analyzed, controlling for clinical center.
Control: Non-TSMB Surgical Day
For each operation, a member of the research team was present in the operating room to collect data. A pre-surgery questionnaire on body part discomfort, pain, and fatigue was given at the start of the surgical day. Then, a questionnaire with these same metrics was completed at the end of each surgery within the surgical day.
Intervention: TSMB Surgical Day
For each operation, a member of the research team was present in the operating room to keep track of time, collect data, and notify the surgeon when TSMB exercises were to be performed. The surgeon decided on best timing to pause and perform the designed exercises.
A standardized (1.5 minutes) TSMB at appropriate 20 to 40-minute intervals throughout each case targeted the neck, shoulders, upper back, lower back, wrists, hands, knees, and ankles. Five standardized exercises were used: neck flexion, extension and lateral rotation (see Figures, Supplemental Digital Contents 2 to 5, https://links.lww.com/SLA/A978, which demonstrate neck exercises); backward shoulder rolls with chest stretch (see Figures, Supplemental Digital Contents 6 and 7, https://links.lww.com/SLA/A978, which demonstrate shoulder exercises); upper back and hand stretch (see Figure, Supplemental Digital Contents 8, https://links.lww.com/SLA/A978, which demonstrates the back and hand stretch); low back flexion and extension (see Figures, Supplemental Digital Contents 9 and 10, https://links.lww.com/SLA/A978, which demonstrate low back exercises) with gluteus maximus squeezes; forefoot and heel lifts for lower extremity and ankle stretches (see Figures, Supplemental Digital Contents 11 and 12, https://links.lww.com/SLA/A978, which demonstrate foot and ankle exercises). Each was designed to be performed within 120 seconds easily while maintaining sterile technique.
On the day of surgery, the procedure, technical approach (open vs MIS), procedure duration, and number of exercise breaks during each, when applicable, were recorded. Additional intraoperative data collected included pain immediately before, during, and after each operative case in the following anatomic regions: neck, shoulders, upper back, lower back, arms, wrists, hands, legs, knees, ankles, and feet. Following the surgery, participants ranked the anatomic regions in decreasing order of discomfort. They were asked to rate the following for each case: complexity, mental and physical demand, degree of difficulty, and environmental distractions. In addition, they were asked whether TSMB helped their physical function and mental focus. Finally, participants were asked whether they wanted to incorporate TSMB in their operating routines.
A visual analog scale was used to quantify participant responses when applicable. Responses were calculated as mean values, percentages of total respondents, or according to ranked options. All percentage calculations were rounded to the nearest whole number.
A major outcome was change in self-reported pain from the beginning of the day to the end of the final procedure, controlling for the total number of minutes spent operating during the day. We calculated change as pain at the end of day minus beginning of day.
Linear mixed models were used to test for an association between pain and the targeted micro breaks intervention. Random intercepts for surgeons, with surgeons nested in clinical site, were used to account for 2 days per surgeon. Complete case analysis was used for each body part; surgeons not providing self-reported pain data on both days for a certain body part were excluded from that body part analysis. Statistical significance was set at 0.05 (Bonferroni adjustment for measurement on 11 body parts).
Pain score analysis results were analyzed and reported per operative case per surgeon. Survey responses with regard to surgeon opinions were reported per surgeon.
Sixty-six participants took part: 61 attending surgeons, 1 MIS fellow, 1 general surgical resident, 2 nurse assistants, and 1 physician assistant. Participants represented a variety of specialties, including general/MIS, colorectal, orthopedics, hepatobiliary, urology, and obstetrics/gynecology. Participants’ mean age and BMI were 47 years and 26 kg/m2, respectively; 69% were men and 31% were women. The majority (80%) reported exercising >4 times/week. Overall, mean operative experience was 13 years with open surgery and 10 years with laparoscopic surgery. Seventy-four percent reported operating 2 to 3 days per week and 69% performed 3 to 4 surgeries per day. Hand dominance was reported as 87% right hand, 7% left hand, and 7% ambidextrous. Mean glove size was 7.
Participants reported regularly experiencing pain during surgery after a mean of 81 minutes. Sixty-seven percent of participants related they regularly felt the need to work through their pain to complete their operative schedule. Average pain scores were similar during open (4.6/10) and laparoscopic (4.5/10) surgery with regions of greatest pain in decreasing order being neck, lower back, shoulders, upper back, wrists/hands, knees, and ankles (Fig. 1). The pain most often impacted posture (68%), stamina (39%), mobility (31%), and concentration (31%) (Fig. 2). The least impact was on lost work days (3.1%).
The most common strategies to counter musculoskeletal pain were changing position (60%), taking a break (34%), adjusting some aspect of the surgical field (29%), using a step stool to change their height (26%), and ignoring their pain (26%). Time away from the operating room was the least utilized strategy (4.4%). Fifteen percent of participants had sought treatment for their pain. Figure 3 illustrates these findings.
Participants also reported that their pain generally continues after surgery with near 3/10 intensity and generally improves within 1 to 2 days after performing surgery. Nevertheless, when asked about their pain in the last 24 hours, 80% reported pain and fatigue, with both interfering to some degree (51% of the time for each) with their personal relations and sleep. Overall, 40% of surgeons were concerned that the impact of their pain would shorten their careers.
Targeted Stretch Micro Breaks (TSMB)
Participants completed a total of 341 surgeries, 193 non-TSMB, and 148 TSMB procedures. Operative procedures spanned a broad category of specialties but excluded cardiac and neurosurgery for logistical reasons (Table 1). Of the 193 non-TSMB surgeries, 140 (73%) were open, 47 (24%) were MIS, and 6 (3%) were robotic. Of the 148 TSMB surgeries, 98 (66%) were open, 42 (28%) were MIS, and 8 (5%) were robotic. Mean operative times between TSMB (133 minutes) and non-TSMB (128 minutes) groups did not significantly differ (P = 0.40). The mean number of stretch breaks per TSMB surgery was 3, taking place every 20 minutes (86%) or 40 minutes (14%).
Participants reported that their fatigue and pain was most pronounced immediately after performing surgery in relation to both TSMB and non-TSMB procedures. Nevertheless, TSMB improved surgeon postprocedure pain scores in all anatomic regions, including the neck, lower back, shoulders, upper back, wrists/hands, knees, and ankles (Table 2). Anatomic regions were ranked according to benefit from TSMB in decreasing order: neck, right wrist, right shoulder, low back, upper back, left shoulder, left wrist, left ankle, right ankle, right knee, and left knee (Fig. 4). Finally, TSMB and non-TSMB surgeries were statistically equivalent with respect to complexity (P = 0.23), physical demand (P = 0.06), mental demand (P = 0.49), distractions (P = 0.40), and degree of difficulty of procedure (P = 0.43).
The benefit of TSMB was compared between open and MIS operations. Pain scores improved with incorporation of TSMB in both open and MIS cases for nearly all anatomic regions, including the neck, shoulders, hands, and lower back (Table 3). MIS surgeries with TSMB had greater improvement in knee pain than open surgeries with TSMB (right knee, P = 0.03; left knee, P = 0.05). Open surgeries with TSMB had greater improvement in upper back pain compared to MIS with TSMB (P= 0.03). Overall, open and MIS TSMB surgeries were statistically equivalent (P > 0.05) with respect to score improvements in most body regions.
The majority of participants using TSMB perceived improvements in physical performance (57%). Thirty-eight percent related improved mental focus (38%). Finally, 87% of respondents wanted to incorporate TSMB in their operating rooms in the future.
With the ever-increasing complexities of operative care and procedures, surgeons are more subject to ergonomic risk factor violations today than ever before. Our study sought initially to characterize and quantify the impact of pain imposed by both MIS and open surgery on its practitioners. The results were alarming with surgeons reporting pain at almost 5/10 following a routine day's work in the operating room. Our study also highlighted the fact that surgeons seldom seek care and often function through their pain with minimal time away from the operating room in order to take care of their patients. Considering these findings in the context of the participant population and culture of surgery, it can safely be inferred that they are likely understated. These surgeon behaviors, while reflecting dedication to their patients, raise serious questions regarding the impact of sustained levels of pain on surgeon function and mental focus and on potential career longevity. Perhaps most important, the effects of these symptoms on the quality of care delivered to patients must be considered and assessed.
Our study additionally revealed that surgeon pain persists beyond the operating room to impact their personal lives, as reflected by interruptions in relationships and sleep. These disturbances may eventually culminate in surgeon burnout. Sleep deprivation has been implicated as a major contributor to professional burnout.26,27 Striking the right work/life balance has been promoted as paramount in the prevention of burnout,28 although it is often very difficult to achieve.
The preliminary survey findings revealed individualized interventional strategies to counter fatigue and pain in the operating room. The majority of participants reported using positional adjustments, intraoperative breaks, or step stools to counter their pain. Positional change has previously been reported in other studies as the most prevalent counter-strategy used.17 Prior studies have also investigated breaks during surgery as a way to manage fatigue, pain, and mental stress in surgeons. Engelmann et al18 randomized surgeons to perform operations in the conventional manner vs taking 5-minute breaks every half hour during surgery. These breaks were simple pauses involving no surgeon activity, thus allowing for a brief period of rest and refocus. They found that breaks enhanced performance and reduced fatigue, strain, pain, stress/workload hormone levels (cortisol and testosterone), intraoperative “events,” and error rates for surgeons without significant prolongation of operative times. In another study, such interventions were investigated to determine adverse outcomes on patient care.29 They were not found to negatively affect patient care, and may have contributed to improved communication between members of the team during breaks.
Several factors may be responsible for the dearth of prospective studies on the ergonomic hazards of surgery. One is the difficulty of inserting research personnel into operating rooms to interrupt operative flow and study the impact of these breaks. Such studies also often measure subjective parameters such as pain and fatigue, which can render any concrete assessments difficult and broad applications speculative. Finally, due to the subjective parameters and lack of an extensive research background in this field, assessment tools are not yet completely developed nor validated.
In conducting our study investigating the impact of imposed micro breaks during surgery on surgeon function and mental focus, we faced challenges similar to the ones just addressed. As well, at the conclusion of our study, we had collected a vast amount of data, including questionnaire responses, pain scores, and direct survey questions posed to surgeons. These data had to be organized and presented to our readers in a manner making optimal sense. Arguably, to combine and present all the data per surgeon as opposed to each body part of each surgeon for each case would offer a more blunt and less representative presentation of the data, likely compromised in power and lacking in more subtle findings.
We anticipated, for instance, that our particular study population would likely understate their pain, based on the culture of surgery, which is discouraging of personal complaints and demanding of performance. Thus, although our data were statistically analyzed, we did not depend on statistical significance alone to confer relevance to our findings. Instead, we relied on 2 main factors in order to assess pain improvement derived from TSMB. We used subjects as their own controls, comparing their pain scores when they employed TSMBs and when they did not. We additionally asked each participant to relate their overall experience with TSMB and any perceived benefits.
Evaluating the impact on participants who did the interventional TSMB, we found that their reduced pain scores indicated they benefited in all major anatomic regions of the body most affected by the stresses of surgery. Performing surgery subjected all participants to pain. When incorporated during surgery, TSMBs were determined to diminish the impact of pain on body parts, performance, and mental focus. This is consistent with the majority (57%) of participants relating that they derived gains in physical function from the exercise breaks. Furthermore, 87% related they would incorporate the practice of TSMBs into their operating room routine. Several possibilities may account for the deficit between those who acknowledged the benefits of TSMB and those who did not but still wanted to incorporate it into their operating rooms. There may be an element of understatement by some who benefited from TSMBs but simply did not fully disclose that. Certain participants may have felt better with TSMB, but not necessarily noticed improved physical function or mental focus. Other benefits of TSMB show promise such as improved opportunities for “cohorted” communication among the operative staff or as welcome and nondistracting levity during a long case.
We found that TSMB benefited nearly all anatomic regions in those performing both open and MIS. No overall difference was found between groups. The results indicate that both open and MIS present with unique ergonomic hazards that are responsive equally and favorably to use of TSMB with participants in open surgery benefitting more from improved upper back pain and those performing MIS benefitting more from improved knee pain. These findings highlight the potential to globally benefit surgeons irrespective of their operative approach.
Use of TSMB offers a novel, practical solution to counter the fatigue and pain that present as seemingly inevitable ergonomic challenges encountered by those performing surgery. Improvement of the physical function and mental focus of surgeons through TSMB incorporation during surgery may occur without lengthening operative times or creating distraction. A next step should undertake to evolve and tailor TSMB exercises to the specific needs of the individual surgeon. Studies to assess benefits, especially long term, and hazards of TSMB regularly integrated within surgery performance are needed. The impact of such measures on patient safety remains to be defined. Continuing efforts to address ergonomic risk factors and solutions will contribute in optimizing surgeons’ productivity, well being, and longevity, all factors contributory to maximizing patient safety in the operating room.
We thank all surgeons who participated in these trials, Rosemary Klein for all her editing efforts and contributions in the preparation of this manuscript, and Mayo's Return to Work Nursing support, specifically Donna Lawson, Gary Seegmiller, and Kerry Allison.
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