Ergonomic endoscopy: An oxymoron or realistic goal?

The current endoscope design is not ergonomic. There is a high prevalence of endoscopy-related injury reported in the literature, and studies have demonstrated high-risk biomechanical exposures during the performance of routine colonoscopy. Endoscopy ergonomics focuses on understanding the endoscopist's interaction with the endoscope and the endoscopy unit and re-designing these tasks to minimize the risk of endoscopy-related injury. The discussion to date has focused on what the endoscopist can do to minimize his or her risk of injury. It is imperative that we re-frame that discussion because the implication that physicians are responsible for implementing personal or workplace interventions places an undue burden on physicians and will be the least effective exposure control method. Endoscope companies need to consider the endoscopist in their design process. As a profession, we need to collectively advocate for endoscopist safety. We offer a perspective on how ergonomic endoscopy can become a realistic and achievable goal. The current endoscope design is not ergonomic. There is a high prevalence of endoscopy-related injury reported in the literature, and studies have demonstrated high-risk biomechanical exposures during the performance of routine colonoscopy. Endoscopy ergonomics focuses on understanding the endoscopist's interaction with the endoscope and the endoscopy unit and re-designing these tasks to minimize the risk of endoscopy-related injury. The discussion to date has focused on what the endoscopist can do to minimize his or her risk of injury. It is imperative that we re-frame that discussion because the implication that physicians are responsible for implementing personal or workplace interventions places an undue burden on physicians and will be the least effective exposure control method. Endoscope companies need to consider the endoscopist in their design process. As a profession, we need to collectively advocate for endoscopist safety. We offer a perspective on how ergonomic endoscopy can become a realistic and achievable goal. Survey-based studies report a 39% to 89% prevalence of potential work-related musculoskeletal disorders in endoscopists,1Battevi N. Menoni O. Cosentino F. et al.Digestive endoscopy and risk of upper limb biomechanical overload.Med Lav. 2009; 100: 171-177PubMed Google Scholar, 2Kuwabara T. Urabe Y. Hiyama T. et al.Prevalence and impact of musculoskeletal pain in Japanese gastrointestinal endoscopists: a controlled study.World J Gastroenterol. 2011; 17: 1488-1493Crossref PubMed Scopus (27) Google Scholar, 3Hansel S.L. Crowell M.D. Pardi D.S. et al.Prevalence and impact of musculoskeletal injury among endoscopists.J Clin Gastroenterol. 2009; 43: 399-404Crossref PubMed Scopus (40) Google Scholar, 4Byun Y.-H. Lee J.-H. Park M.-K. et al.Procedure-related musculoskeletal symptoms in gastrointestinal endoscopists in Korea.World J Gastroenterol. 2008; 14: 4359-4364Crossref PubMed Scopus (36) Google Scholar, 5Liberman A.S. Shrier I. Gordon P.H. Injuries sustained by colorectal surgeons performing colonoscopy.Surg Endosc. 2005; 19: 1606-1609Crossref PubMed Scopus (55) Google Scholar, 6Ridtitid W. Coté G.A. Leung W. et al.Prevalence and risk factors for musculoskeletal injuries related to endoscopy.Gastrointest Endosc. 2015; 81: 294-302.e4Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar highlighting the need for a better understanding of the risk factors for endoscopy-related injury. Ergonomics is the science of designing tasks to fit within the physical and cognitive capabilities and limitations of the breadth of users.7The Eastman Kodak CompanyKodak's ergonomic design for people at work. John Wiley, Hoboken, NJ2004Google Scholar Endoscopy ergonomics focuses on understanding the endoscopist's interaction with the endoscope and the endoscopy unit, and re-designing these tasks to minimize risk of endoscopy-related injury. Established risk factors for work-related musculoskeletal injury include repetition, high forces, especially when combined with non-neutral postures, and the percentage of time the hand is engaged in high-risk pinching.8Rempel D.M. Harrison R.J. Barnhart S. Work-related cumulative trauma disorders of the upper extremity.JAMA. 1992; 267: 838-842Crossref PubMed Scopus (295) Google Scholar, 9Harris-Adamson C. Eisen E.A. Kapellusch J. et al.Biomechanical risk factors for carpal tunnel syndrome: a pooled study of 2474 workers.Occup Environ Med. 2015; 72: 33-41Crossref PubMed Scopus (112) Google Scholar, 10Harris-Adamson C. You D. Eisen E.A. et al.The impact of posture on wrist tendinosis among blue-collar workers: the San Francisco study.Hum Factors. 2014; 56: 143-150Crossref PubMed Scopus (18) Google Scholar We have demonstrated high-risk exposures during routine colonoscopy,11Shergill A. Harris-Adamson C. Lee D.L. et al.Ergonomic evaluation of colonoscopy: assessment of biomechanical risk factors associated with distal upper extremity musculoskeletal disorders in endoscopists performing routine colonoscopy [abstract].Gastrointest Endosc. 2016; 83: AB180Abstract Full Text Full Text PDF Google Scholar, 12Shergill A.K. Asundi K.R. Barr A. et al.Pinch force and forearm-muscle load during routine colonoscopy: a pilot study.Gastrointest Endosc. 2009; 69: 142-146Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar and the risk is likely greater for women than men. The application of ergonomics to endoscopy is necessary to optimize the endoscopy work environment and improve the overall well-being of the endoscopist. Endoscopy ergonomics makes intuitive sense. Many key tenets in ergonomics, such as maintaining neutral postures and working in the position of greatest strength, hark back to basic biomechanics learned as medical students. Another fundamental concept, designing for the spectrum of potential users instead of the current one-size-fits-all design, appears completely logical but somehow has been ignored by the major endoscope companies. When we think about the practice of endoscopy 40 years ago (in the 1980s, when flexible video-endoscopes were first introduced), it is remarkable how little has changed in basic endoscope mechanical design despite enormous advances in optics. In keeping with their origins as camera companies, the endoscope manufacturers have evolved the instruments to take beautiful images that can be manipulated by filters or postprocessing algorithms to enhance detection and characterization of lesions. However, the basic design of the endoscope remains unchanged. We would never think to drive a car whose seat or steering wheel could not be adjusted to our body dimensions, yet every day, we drive endoscopes that were not designed with the operator in mind. We offer the following perspective on endoscopy ergonomics: The endoscope is a failure of an engineered system, and endoscopist injury is the result of this failed system.13Shergill A.K. Harris Adamson C. Failure of an engineered system: the gastrointestinal endoscope.Tech Gastrointest Endosc. 2019; 21: 116-123Abstract Full Text Full Text PDF Scopus (13) Google Scholar There should be no stigma associated with work-related endoscopist injury. An endoscopist receives an injury not because they are weak or poorly trained, but because the endoscope was poorly designed. Human-centered design requires that the potential users be considered when designing a tool or a task. Users should be able to use a tool safely, efficiently, and effectively. The endoscope, however, is currently a one-size-fits-all design. In one study of gastroenterology fellows, most fellows with a hand size <6.5, mostly women, felt that the endoscope was too large for their hands and impeded their ability to learn endoscopy.14Cohen D.L. Naik J.R. Tamariz L.J. et al.The perception of gastroenterology fellows towards the relationship between hand size and endoscopic training.Dig Dis Sci. 2008; 53: 1902-1909Crossref PubMed Scopus (21) Google Scholar Holding the endoscope with a suboptimal grip also disadvantages the user, because a suboptimal grip results in a decreased ability to produce force.7The Eastman Kodak CompanyKodak's ergonomic design for people at work. John Wiley, Hoboken, NJ2004Google Scholar Our ability to maximally produce force occurs when the actin and myosin filaments are maximally overlapped, as occurs during neutral postures in a power grip. Any deviation from neutral posture results in a decrease in that muscle's maximal voluntary contraction. In addition to having smaller hands, women have a fraction of the force-generation ability of men. The ability to generate force is dependent on sheer muscle mass, and men on average have 11.8 kg (26 lb) more muscle mass them women.15Janssen I. Heymsfield S.B. Wang Z. et al.Skeletal muscle mass and distribution in 468 men and women aged 18–88 yr.J Appl Physiol. 2000; 89: 81-88Crossref PubMed Scopus (1800) Google Scholar This results in females having approximately 50% of male strength overall,16Miller A.E.J. MacDougall J.D. Tarnopolsky M.A. et al.Gender differences in strength and muscle fiber characteristics.Eur J Appl Physiol. 1993; 66: 254-262Crossref PubMed Scopus (672) Google Scholar with significant discordance in pinch and grip force-generation abilities. Ninety percent of females have a maximal pinch force that is less than 95% of males.17Leyk D. Gorges W. Ridder D. et al.Hand-grip strength of young men, women and highly trained female athletes.Eur J Appl Physiol. 2007; 99: 415-421Crossref PubMed Scopus (94) Google Scholar Women are at their strongest in their 20s, and even at their strongest are typically as strong as 70- to 80-year-old men.18Nilsen T. Hermann M. Eriksen C.S. et al.Grip force and pinch grip in an adult population: reference values and factors associated with grip force.Scand J Occup Ther. 2012; 19: 288-296Crossref PubMed Scopus (56) Google Scholar Thus, women are working far harder than their male counterparts to perform the same endoscopic manipulations, and the risk of repetitive strain injury is compounded if they use a suboptimal grip, which results in an additional biomechanical disadvantage. Standard design criteria require that the breadth of users be considered, such that the endoscope can be held comfortably and manipulated easily by the smallest, 5th percentile female and the largest, 95th percentile male.7The Eastman Kodak CompanyKodak's ergonomic design for people at work. John Wiley, Hoboken, NJ2004Google Scholar These standard design criteria are clearly not being met. Survey-based studies have documented a high prevalence of endoscopist-related injury, and the risk of injury seems to increase with increased volume of endoscopies.6Ridtitid W. Coté G.A. Leung W. et al.Prevalence and risk factors for musculoskeletal injuries related to endoscopy.Gastrointest Endosc. 2015; 81: 294-302.e4Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar The 2015 survey of American Society for Gastrointestinal Endoscopy (ASGE) members found that most physicians are now spending >40% of their time performing endoscopy.6Ridtitid W. Coté G.A. Leung W. et al.Prevalence and risk factors for musculoskeletal injuries related to endoscopy.Gastrointest Endosc. 2015; 81: 294-302.e4Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar In stark contrast, 20 years ago, most physicians reported spending <40% of their time performing endoscopy.19Buschbacher R. Overuse syndromes among endoscopists.Endoscopy. 1994; 26: 539-544Crossref PubMed Scopus (56) Google Scholar Despite the high prevalence of reported injury, we have not been successful in creating a "culture of safety" in our workplaces. Even though almost every physician has a story of endoscopy-related pain or injury, endoscopists do not feel comfortable discussing work-related symptoms. The reasons are unclear, and this has not been systematically studied for medical professionals. Previous studies of under-reporting of work-related disorders hypothesized that it may be related to a perception of adverse effects on an individual's reputation, lifestyle, or livelihood.20Pransky G. Snyder T. Dembe A. et al.Under-reporting of work-related disorders in the workplace: a case study and review of the literature.Ergonomics. 1999; 42: 171-182Crossref PubMed Scopus (246) Google Scholar In one case study of industrial workers, reasons for not reporting their injuries included fear of reprisal, a belief that pain was an ordinary consequence of work activity or aging, a desire not to place additional burdens on their co-workers, and lack of management responsiveness to previous reports.20Pransky G. Snyder T. Dembe A. et al.Under-reporting of work-related disorders in the workplace: a case study and review of the literature.Ergonomics. 1999; 42: 171-182Crossref PubMed Scopus (246) Google Scholar These reasons likely resonant with GI physicians. Significant resources have been devoted to patient safety initiatives, including the annual publication of Joint Commission's National Patient Safety Goals. A similar "Health Care Employee Safety Goal" initiative does not exist and is badly needed. Endoscopic ergonomics should be integrated into the training and orientation process for every endoscopy unit, and a culture of safety needs to be established. Employees of managed care organizations need to know that their management is committed to safety. Private practitioners need to feel safe reporting pain, because this is often the first sign of injury, and in requesting a reduced workload to allow for adequate rest and recovery. Practitioners experiencing pain or injury should know that they have the support of the administration to implement workplace practices to rest and recover, reduce their exposure, and develop a sustainable plan for continuing endoscopy. Most importantly, the endoscopist should not be left to "figure it out." Given the high prevalence of injury, this will be an issue for every endoscopy unit at one time or another, and organizations should proactively develop a plan instead of reacting when an injury inevitably occurs. In the "hierarchy of controls" to mitigate risk by reducing or eliminating exposures, the operators are at the bottom of an upside-down pyramid.13Shergill A.K. Harris Adamson C. Failure of an engineered system: the gastrointestinal endoscope.Tech Gastrointest Endosc. 2019; 21: 116-123Abstract Full Text Full Text PDF Scopus (13) Google Scholar To date, the question that the endoscopist most often asks is, "What can I do…to prevent injury?" The discussion has focused on the modifiable elements of the endoscopy unit: monitor position and height, bed height, and neutralizing postures. Optimal technique may minimize force production, but what constitutes "optimal technique" is up for debate. Striving for a short, straight, and soft scope orientation that is maximally responsive to tip deflection and torque will minimize the force required to perform diagnostic and therapeutic endoscopy. Some have advocated that endoscopists should train as athletes to improve strength and flexibility.21Siau K. Anderson J.T. Ergonomics in endoscopy: should the endoscopist be considered and trained like an athlete?.Endosc Int Open. 2019; 07: E813-E815Crossref Google Scholar However, the implication that physicians are responsible for implementing personal or workplace interventions places an undue burden on the physicians and will be the least effective exposure control method. The "hierarchy of controls" represents Occupational Safety and Health Administration's recommendation for controlling exposures and mitigating the risk of work-related injury (Fig. 1).22The National Institute for Occupational Safety and Injury (NIOSH)Hierarchy of controls.https://www.cdc.gov/niosh/topics/hierarchy/default.htmlDate: 2015Date accessed: August 8, 2019Google Scholar We, the endoscope operators, are at the bottom of the hierarchy of effective exposure controls. The most effective methods of reducing risk to the endoscopist are "elimination" and "substitution" of hazards, which embrace the concept of prevention through design.23The National Institute for Occupational Safety and Injury (NIOSH)Prevention through design.https://www.cdc.gov/niosh/topics/ptd/default.htmlDate: 2018Date accessed: August 8, 2019Google Scholar This requires engagement and buy-in from endoscope companies to develop a safer and more user-friendly endoscope, one that starts with the endoscopist at the forefront of the design process. Engineered controls, which isolate the hazard, are the next most effective method of reducing work-related exposures and thus, injury. In endoscopy, this might include tools that optimize our interaction with the endoscope, such as right/left assist dials, endoscope support stands, or endoscope caps.13Shergill A.K. Harris Adamson C. Failure of an engineered system: the gastrointestinal endoscope.Tech Gastrointest Endosc. 2019; 21: 116-123Abstract Full Text Full Text PDF Scopus (13) Google Scholar This also includes tools that optimize our interaction with our work environment, such as adjustable monitors and beds that allow for neutral postures during the performance of endoscopy. The next most effective method is administrative controls, which controls exposures through policies and workplace practices. One example of an administrative control is the endoscopy schedule. Back-to-back full days of endoscopy may not allow adequate time for rest or recovery. Ideally, schedules should ensure that physicians have adequately recovered from the previous endoscopy session before they are scheduled for another day or half-day of endoscopy. Administrative policies should include an endoscopy ergonomics program that ensures ergonomic training for all members of the endoscopy team, and implements a pre-procedure ergonomic time-out. The least effective methods for reducing work-related injury are "personal protective equipment" or endoscopist-driven interventions to control exposure.13Shergill A.K. Harris Adamson C. Failure of an engineered system: the gastrointestinal endoscope.Tech Gastrointest Endosc. 2019; 21: 116-123Abstract Full Text Full Text PDF Scopus (13) Google Scholar These are essential but will not be effective if they are the only control measures implemented. Thus, although maintaining physical fitness and maximizing strength and flexibility can be endorsed as part of a healthy lifestyle, they cannot be recommended as effective means to reduce endoscopy-related injury. A young female endoscopist should not have to enroll in a strength training program in order to perform endoscopy safely. All of us became physicians to pursue the noble cause of patient care and have been taught to always put the patient first. However, this "patient first" perspective has led to unintended consequences, whereby the physician's needs can be inadvertently subordinated, forgotten, or dismissed. The physician has to figure out how to perform an endoscopy while twisted in unnatural positions looking at ill-placed monitors that have been moved out of the way to accommodate the anesthesia cart. The patient deserves to be the central character; after all, that is why the team has assembled in the unit. But once the procedure starts, the endoscopist is the star—the main performer, the reason the patient, the nurse, and the anesthesiologist are gathered in that endoscopy suite. The nurse and the anesthesiologist can take a break. The endoscopist cannot. The endoscopist needs to ensure that the monitor and bed position are optimized so that they can maintain a neutral posture during the examination, and they need to be empowered to speak up for their needs. An ergonomic time-out before the initiation of the procedure can ensure proper positioning and height of the monitor and bed, such that head, neck, back, shoulder, and elbow postures are neutral. This requires the use of adjustable monitors and beds, and for the monitor to be placed directly in front of the endoscopist just below eye level (Fig. 2).24Shergill A.K. McQuaid K.R. Rempel D. Ergonomics and GI endoscopy.Gastrointest Endosc. 2009; 70: 145-153Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar To preserve our talented endoscopy work force, we should treat our endoscopists like the stars that they are. In the 2015 ASGE study, only 10% of endoscopists took regular breaks, and one-third took no breaks.6Ridtitid W. Coté G.A. Leung W. et al.Prevalence and risk factors for musculoskeletal injuries related to endoscopy.Gastrointest Endosc. 2015; 81: 294-302.e4Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar We need to give our muscles, tendons, and ligaments a chance to recover from the strain of performing an endoscopy. Scheduled breaks are optimal. At the very least, we should be implementing micro-breaks into our practices. We should not be starting a day of endoscopy still sore and recovering from the last set of procedures. We need to respect pain; it is an important signal from the body. As the endoscope ages and the cables of the endoscope become less responsive, additional force may be required to achieve the same degree of tip deflection. Unfortunately, only one endoscope company recommends proactive endoscope maintenance after a prescribed number of procedures. Unless the endoscopes are under warranty or being leased, endoscopists may be working with suboptimal performing endoscopes, which is a concern, since optimally performing endoscopes already pose a high risk. Endoscope companies need to do a better job of understanding the biomechanical exposures during endoscopy, and while working on solutions to eliminate or substitute those exposures, they need to be our partners in maintaining the optimal performance of the scopes. The best time to purchase disability insurance is when you are young, healthy, and do not need it. The old adage "fail to plan, plan to fail," applies here. Think about disability insurance early in your career and seek expertise to guide you. There are many considerations, including own occupation versus any occupation disability, short versus long term, and the option for many different kinds of riders, all of which can increase the cost of disability insurance but also increase the payout during the time of disability. For example, a future increase option allows you to apply for additional disability insurance coverage, regardless of health, as your income increases. A cost of living adjustment rider will help any benefits that you are paid keep pace with inflation. A partial or residual disability benefit pays benefits in the event of a partial loss of income, such as when you return to work after an injury, but with a reduced endoscopy workload. This rider will cover the lost income. Is "ergonomic endoscopy" an oxymoron or a realistic goal? The current endoscope design is not ergonomic. Until the endoscope companies decide to make the endoscopist a central part of their design process, endoscopy will continue to be associated with risk factors that endanger the longevity of the endoscopic workforce, especially in an era of high-volume, high-complexity procedures. In the face of fundamental problems in instrument design, it is imperative that we implement the engineering, administrative, and personal controls that will mitigate exposures to the best of our ability. We must try to minimize injury by designing an endoscopy suite and a workday that applies basic ergonomic principles, such as neutralizing postures, minimizing forces, and allowing for adequate rest between procedures. As a profession, we must advocate collectively for physician safety so that ergonomic endoscopy can finally become a realistic and achievable goal.