User login
Dear colleagues,
We are all part of one of the most exciting and varied fields of medicine and hope to have long and productive careers. In this month’s AGA Perspectives we explore two different impediments to longevity as a gastroenterologist: work-related disability and burnout.
Physician burnout has reached almost epidemic levels in medicine and is best approached in a multimodal manner, incorporating both institutional and individual changes. Dr. Sumeet Tewani discusses ways in which groups and institutions can foster physician wellness to reduce burnout. In particular, he will explore how flexibility in work schedules, among other initiatives, can improve workplace morale. In an accompanying perspective, Dr. Anna Lipowska and Dr. Amandeep Shergill explore how to incorporate ergonomics in endoscopy to prevent injury. Endoscopic practice, with its repetitive tasks and physical demands, can predispose to injury at all levels of training and experience. Ergonomics is thus a critical topic that is unfortunately covered too little, if at all, in our endoscopy training.
We hope these essays will help your medical practice and welcome your thoughts on these important issues at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Fostering physician wellness to prevent burnout
BY SUMEET TEWANI, MD
Gastroenterology can be a challenging field, both professionally and personally, as it requires providers to have high clinical knowledge, expertise, and emotional intelligence. Burnout is a state of emotional, physical, and mental exhaustion, depersonalization, and a reduced sense of personal accomplishment, caused by prolonged or excessive stress. Burnout can be a serious and progressive chronic condition that negatively impacts the provider and patient experience, with serious consequences on the provider’s health, job performance, patient satisfaction, and personal relationships.
Adopting strategies to combat burnout are of vital importance to promoting provider wellness, a healthy work environment, and positive interactions with colleagues, staff, and patients. This also positively impacts providers’ out-of-work experiences and relationships. on an institutional level and on an individual level.
Multiple factors affecting burnout have been identified, including individual factors, work volume, professional risk and responsibility, resources, and relationships with colleagues and patients. Practicing gastroenterology frequently requires long and irregular work hours, heavy workloads, large panels of complex patients, invasive procedures, and high amounts of stress. Additional stressors may include an inefficient work environment, inadequate support, and loss of value and meaning in work. Nearly 50% of physicians meet criteria for burnout, citing such reasons as excessive bureaucratic tasks, lack of control, flexibility and autonomy, lack of peer respect, increasing computerization of practice, and lack of respect from patients.
Preventing burnout
When coping with burnout, many providers choose positive mechanisms such as exercise, listening to music, meditation, and talking with family and friends. Others become more isolated, eat junk food or binge eat, or turn to drug or alcohol abuse. Our primary approach to preventing burnout at an individual level is to ensure providers have access to self-care techniques such as stress management and mindfulness, and to encourage wellness with regular exercise and healthy habits. Promoting a culture of work-life balance requires providing adequate time for personal activities and hobbies, rest, relaxation, and spending time with family and friends. Allowing providers to personally shape their career paths aligns their personal and professional goals, leading to greater satisfaction. To this end, providers may become involved in clinical research, medical education, and clinical and administrative committees through the practice, local medical school and hospitals, and local and national societies. We provide ample vacation time and CME opportunities for our providers. Vacation time is flexible and can be taken in half-day or full-day increments, or on an hourly basis for personal time as necessary. This allows for enhanced flexibility with scheduling time off from work.
On an institutional level, leadership plays a prime role in creating a healthy work environment. Having good leaders influences the well-being and satisfaction of everyone within the organization. Leaders can have a positive impact by aligning values and work culture, using incentives in a productive manner, and promoting strategies to reduce burnout. Involving physician partners in leadership on a rotating basis allows them to better understand the roles of the leaders in the organization and empowers them to have a voice in changing policies to reduce administrative burdens and foster wellness.
We promote the concept of working together as a team for the success of the practice. All partners have an equal say in the management of the group. We eliminated the stress of competition within the group, equalizing pay across all physician partners, while maintaining equal exposure to work and equal time off from work. This levels the playing field between physicians who have varied interests and expertise, so that everyone is working towards the success of the practice and not individual compensation. To that end, our providers do not have individual offices, but work out of a “bullpen” with an open concept where we have individual workspaces and interact with each other continuously throughout the day. This promotes cohesion and teamwork between the providers for all our patients and promotes professional relationships and peer support. Efforts to promote workplace morale include access to a fully stocked deli and a newly installed espresso machine.
The concept of teamwork
The concept of teamwork also needs to pervade through the entire organization. To manage the demands of a busy workday, we have directly trained advanced practice nurses in the clinic and inpatient settings, allowing our physicians to increase throughput and procedures while maintaining a high level of patient care, satisfaction, and efficiency. Providers report excessive administrative tasks and frustration with the electronic health record as major factors contributing to burnout. Delegating tasks to staff, commensurate with their training and scope of practice, alleviates some of this burden. Each of the providers in our practice has a triage nurse who functions in a key capacity to ensure the appropriate clinical and administrative tasks are complete. Medical scribes, medical assistants, nurses, and physician assistants can be utilized for data entry and other tasks. We have developed templates within the electronic health record that can be standardized across the practice. Promoting teamwork with staff also means respecting the staff and understanding their needs. A highly functioning health care team can provide comprehensive care proactively and efficiently, with improved professional satisfaction.
In summary, I identify several ways to promote physician wellness. Every GI practice should strive to implement local approaches to prevent physician burnout and help maintain a happy and productive workforce.
Dr. Tewani is a gastroenterologist with Rockford Gastroenterology Associates in Rockford, Ill. He has no relevant disclosures.
References
1. Koval ML. Medscape gastroenterologist lifestyle, happiness & burnout report 2023: Contentment amid stress. Medscape. 24 Feb 2023.
2. Ong J et al. The prevalence of burnout, risk factors, and job-related stressors in gastroenterologists: A systematic review. J Gastroenterol Hepatol. 2021 Sep;36(9):2338-48.
3. Anderson J et al. Strategies to combat physician burnout in gastroenterology. Am J Gastroenterol. 2017 Sep;112(9):1356-9.
4. Keswani R et al. Burnout in gastroenterologists and how to prevent it. Gastroenterology. 2014 Jul;147(1):11-4.
The hazards of endoscopy: Ergonomics guide the way
BY ANNA LIPOWSKA, MD, AND AMANDEEP SHERGILL, MD, MS
Preventing disability and promoting a long and successful endoscopic career involves proactive measures to support well-being, and ergonomics plays a key role. Ergonomics is the science of fitting a job to the worker, with a primary goal of working smarter and safer. When hazards are identified, mitigation measures, guided by a hierarchy of controls, must be implemented that improve the fit of the tool, task and job to the worker in order to reduce the risk of endoscopy-related injury (ERI). As more women enter the field and as the overall GI physician population ages, ensuring that endoscopy is designed to be safely performed within the capacity of a diverse group of workers will be critical to creating an inclusive and equitable work environment.
Ergonomic education is foundational: Awareness of ERI risk factors allows endoscopists to identify hazards and advocate for effective control solutions. Ergonomic education materials are available through all of the major GI societies. A road map for implementing an endoscopy ergonomics program has been previously published and provides guidance on risk assessment and mitigation measures.
Respect pain
Overuse injuries occur when the physical demands of a job are greater than tissue tolerances, leading to cumulative microtrauma. The first sign of microtraumatic injury is discomfort and pain. Studies have demonstrated that an estimated three-quarters of gastroenterologists experience ERI, with 20% requiring time off work and 12% requiring surgery. Gastroenterology trainees are also at risk, with 20% of surveyed fellows endorsing overuse injury, some even requiring work-related leaves of absence. In the early stages of ERI, aching and tiredness occur during the work shift only. In the intermediate stage, aching and tiredness occur early in the work shift and persist at night, and may be associated with a reduced capacity for repetitive work. In the late stages, aching, fatigue and weakness persist at rest and may be associated with inability to sleep and to perform light duties. Pain is an important signal indicating mitigation measures are required to control exposures.
Utilize the hierarchy of controls
The responsibility for adoption of ergonomically friendly practices does not lie solely with the physician; both institutional and industry-level support are key to its success. The hierarchy of controls defines which actions will best mitigate exposures to hazards in the workplace, highlighting that modifications to personal practice have the smallest impact. Current endoscope design does not accommodate the full range of hand strengths and sizes and contributes to ERI.
Advancements at the industry level by eliminating or substituting hazards, or designing engineering controls to reduce exposure, will be most effective at preventing distal upper extremity ERI. The next most effective controls are at the institutional level, with endoscopy units ensuring access to engineering controls and implementing effective administrative controls. For example, institutional support and investment in adjustable workstations is imperative to accommodate a range of anthropometric dimensions of the population. Support for ergonomic education, scheduling changes and a culture where safety is a priority can help reduce exposure to hazards and injury risk.
Adjust the endoscopy suite to achieve a comfortable position before every procedure
Neutral body posture is our position of greatest comfort and maximum strength, and any deviation from neutral posture decreases the amount of force the muscles can produce and causes the muscles to fatigue sooner. The most important factor affecting the endoscopists’ overall posture is the monitor position and height. Monitors must be adjustable. Place the monitor directly in front of you, with the center of the screen 15-25 degrees below eye height for a neutral neck position and resting eye position. Procedure bed height should be adjusted 0-10 cm below elbow height to allow for neutral elbow postures and relaxed shoulders. Antifatigue mats and shoes with supportive insoles can reduce fatigue. Two-piece lead aprons distribute a portion of the static load to the hips and decrease back strain. Incorporate a preprocedure ergonomic time-out, to assess proper room set up, body mechanics, equipment and team preparedness.
Give yourself a break
Breaks should be built into the endoscopy schedule, especially for a full day of endoscopy. At a minimum, incorporate microbreaks during procedures, which have been found to alleviate pain and improve performance. Exercises and stretching can be incorporated between cases, including routines designed specifically for endoscopists.
Getting older isn’t for the weak
Currently, 50% of our gastroenterologists are over 55 years old. The aging process leads to a distinct muscle mass and strength loss. Women are already at a disadvantage because, on average, they have less muscle mass than men in all age groups. Muscle starts to deteriorate when we reach our 30s, and after age 40, we lose on average 8% of our muscle mass every decade which accelerates at an even faster rate after age 60. Both resistance and aerobic exercise can be very useful to counteract sarcopenia and maintain strength. Given the physical demands of endoscopy, exercise can help safeguard career longevity and maintain overall wellness. Multiple resources are available to tailor a program that fits your time, budget and needs.
Optimize all of your workstations
Prolonged computer use and desk work is also a significant part of a gastroenterologist’s profession. If using a sitting desk, chair height should allow for 90-degree flexion at the hips and knees and for feet to rest flatly on the floor. The chair should also provide adequate back support for a relaxed upright position. Similar to endoscopy, place the monitor directly in front with the center of the screen slightly below eye level. For mouse and keyboard placement, aim to have the elbows at or slightly below 90 degrees and one’s wrists and fingers in neutral position.
Endoscopy can be hazardous to the endoscopists’ health. Incorporating ergonomic principles creates a safer and more efficient work environment. At the individual level, ergonomically optimized postures during endoscopy as well as during computer-related tasks, room set up, inclusion of microbreaks, and protective exercises can help decrease the risk of repetitive strain injury and prevent disability. Importantly, change at the industry and institutional level has the greatest potential for positive impact. Adoption of ergonomic practices promotes career longevity and ensures that gastroenterologists can continue successful and long careers and provide quality care to their patients without compromising their own health.
Dr. Lipowska is an assistant professor in the division of gastroenterology and hepatology, University of Illinois at Chicago. She disclosed no conflicts. Dr. Shergill is chief of gastroenterology for the San Francisco VA Health Care System. She disclosed consulting work for Boston Scientific and Neptune Medical, honoraria for visiting professorship with Intuitive Surgical, and a research gift from Pentax.
References
Shergill AK. Top tips for implementing an endoscopy ergonomics program. Gastrointest Endosc. 2023 Feb;97(2):361-4.
Pawa S et al. Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey. Am J Gastroenterol. 2021;116(3):530-8.
Austin K et al. Musculoskeletal injuries are commonly reported among gastroenterology trainees: Results of a national survey. Dig Dis Sci. 2019;64(6):1439-47.
Lipowska A et al. Ergonomics in the unit: Modeling the environment around the endoscopist. Tech Innov Gastrointest Endosc. 2021;23(3):256-62.
Park A et al. Intraoperative “Micro Breaks” with a targeted stretching enhance surgeon physical function and mental focus: A multicenter cohort study. Ann Surg. 2017;265(2):340-6.
Shergill A et al. Ergonomic endoscopy: An oxymoron or realistic goal? Gastrointest Endosc. 2019;90(6):966-70.
Dear colleagues,
We are all part of one of the most exciting and varied fields of medicine and hope to have long and productive careers. In this month’s AGA Perspectives we explore two different impediments to longevity as a gastroenterologist: work-related disability and burnout.
Physician burnout has reached almost epidemic levels in medicine and is best approached in a multimodal manner, incorporating both institutional and individual changes. Dr. Sumeet Tewani discusses ways in which groups and institutions can foster physician wellness to reduce burnout. In particular, he will explore how flexibility in work schedules, among other initiatives, can improve workplace morale. In an accompanying perspective, Dr. Anna Lipowska and Dr. Amandeep Shergill explore how to incorporate ergonomics in endoscopy to prevent injury. Endoscopic practice, with its repetitive tasks and physical demands, can predispose to injury at all levels of training and experience. Ergonomics is thus a critical topic that is unfortunately covered too little, if at all, in our endoscopy training.
We hope these essays will help your medical practice and welcome your thoughts on these important issues at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Fostering physician wellness to prevent burnout
BY SUMEET TEWANI, MD
Gastroenterology can be a challenging field, both professionally and personally, as it requires providers to have high clinical knowledge, expertise, and emotional intelligence. Burnout is a state of emotional, physical, and mental exhaustion, depersonalization, and a reduced sense of personal accomplishment, caused by prolonged or excessive stress. Burnout can be a serious and progressive chronic condition that negatively impacts the provider and patient experience, with serious consequences on the provider’s health, job performance, patient satisfaction, and personal relationships.
Adopting strategies to combat burnout are of vital importance to promoting provider wellness, a healthy work environment, and positive interactions with colleagues, staff, and patients. This also positively impacts providers’ out-of-work experiences and relationships. on an institutional level and on an individual level.
Multiple factors affecting burnout have been identified, including individual factors, work volume, professional risk and responsibility, resources, and relationships with colleagues and patients. Practicing gastroenterology frequently requires long and irregular work hours, heavy workloads, large panels of complex patients, invasive procedures, and high amounts of stress. Additional stressors may include an inefficient work environment, inadequate support, and loss of value and meaning in work. Nearly 50% of physicians meet criteria for burnout, citing such reasons as excessive bureaucratic tasks, lack of control, flexibility and autonomy, lack of peer respect, increasing computerization of practice, and lack of respect from patients.
Preventing burnout
When coping with burnout, many providers choose positive mechanisms such as exercise, listening to music, meditation, and talking with family and friends. Others become more isolated, eat junk food or binge eat, or turn to drug or alcohol abuse. Our primary approach to preventing burnout at an individual level is to ensure providers have access to self-care techniques such as stress management and mindfulness, and to encourage wellness with regular exercise and healthy habits. Promoting a culture of work-life balance requires providing adequate time for personal activities and hobbies, rest, relaxation, and spending time with family and friends. Allowing providers to personally shape their career paths aligns their personal and professional goals, leading to greater satisfaction. To this end, providers may become involved in clinical research, medical education, and clinical and administrative committees through the practice, local medical school and hospitals, and local and national societies. We provide ample vacation time and CME opportunities for our providers. Vacation time is flexible and can be taken in half-day or full-day increments, or on an hourly basis for personal time as necessary. This allows for enhanced flexibility with scheduling time off from work.
On an institutional level, leadership plays a prime role in creating a healthy work environment. Having good leaders influences the well-being and satisfaction of everyone within the organization. Leaders can have a positive impact by aligning values and work culture, using incentives in a productive manner, and promoting strategies to reduce burnout. Involving physician partners in leadership on a rotating basis allows them to better understand the roles of the leaders in the organization and empowers them to have a voice in changing policies to reduce administrative burdens and foster wellness.
We promote the concept of working together as a team for the success of the practice. All partners have an equal say in the management of the group. We eliminated the stress of competition within the group, equalizing pay across all physician partners, while maintaining equal exposure to work and equal time off from work. This levels the playing field between physicians who have varied interests and expertise, so that everyone is working towards the success of the practice and not individual compensation. To that end, our providers do not have individual offices, but work out of a “bullpen” with an open concept where we have individual workspaces and interact with each other continuously throughout the day. This promotes cohesion and teamwork between the providers for all our patients and promotes professional relationships and peer support. Efforts to promote workplace morale include access to a fully stocked deli and a newly installed espresso machine.
The concept of teamwork
The concept of teamwork also needs to pervade through the entire organization. To manage the demands of a busy workday, we have directly trained advanced practice nurses in the clinic and inpatient settings, allowing our physicians to increase throughput and procedures while maintaining a high level of patient care, satisfaction, and efficiency. Providers report excessive administrative tasks and frustration with the electronic health record as major factors contributing to burnout. Delegating tasks to staff, commensurate with their training and scope of practice, alleviates some of this burden. Each of the providers in our practice has a triage nurse who functions in a key capacity to ensure the appropriate clinical and administrative tasks are complete. Medical scribes, medical assistants, nurses, and physician assistants can be utilized for data entry and other tasks. We have developed templates within the electronic health record that can be standardized across the practice. Promoting teamwork with staff also means respecting the staff and understanding their needs. A highly functioning health care team can provide comprehensive care proactively and efficiently, with improved professional satisfaction.
In summary, I identify several ways to promote physician wellness. Every GI practice should strive to implement local approaches to prevent physician burnout and help maintain a happy and productive workforce.
Dr. Tewani is a gastroenterologist with Rockford Gastroenterology Associates in Rockford, Ill. He has no relevant disclosures.
References
1. Koval ML. Medscape gastroenterologist lifestyle, happiness & burnout report 2023: Contentment amid stress. Medscape. 24 Feb 2023.
2. Ong J et al. The prevalence of burnout, risk factors, and job-related stressors in gastroenterologists: A systematic review. J Gastroenterol Hepatol. 2021 Sep;36(9):2338-48.
3. Anderson J et al. Strategies to combat physician burnout in gastroenterology. Am J Gastroenterol. 2017 Sep;112(9):1356-9.
4. Keswani R et al. Burnout in gastroenterologists and how to prevent it. Gastroenterology. 2014 Jul;147(1):11-4.
The hazards of endoscopy: Ergonomics guide the way
BY ANNA LIPOWSKA, MD, AND AMANDEEP SHERGILL, MD, MS
Preventing disability and promoting a long and successful endoscopic career involves proactive measures to support well-being, and ergonomics plays a key role. Ergonomics is the science of fitting a job to the worker, with a primary goal of working smarter and safer. When hazards are identified, mitigation measures, guided by a hierarchy of controls, must be implemented that improve the fit of the tool, task and job to the worker in order to reduce the risk of endoscopy-related injury (ERI). As more women enter the field and as the overall GI physician population ages, ensuring that endoscopy is designed to be safely performed within the capacity of a diverse group of workers will be critical to creating an inclusive and equitable work environment.
Ergonomic education is foundational: Awareness of ERI risk factors allows endoscopists to identify hazards and advocate for effective control solutions. Ergonomic education materials are available through all of the major GI societies. A road map for implementing an endoscopy ergonomics program has been previously published and provides guidance on risk assessment and mitigation measures.
Respect pain
Overuse injuries occur when the physical demands of a job are greater than tissue tolerances, leading to cumulative microtrauma. The first sign of microtraumatic injury is discomfort and pain. Studies have demonstrated that an estimated three-quarters of gastroenterologists experience ERI, with 20% requiring time off work and 12% requiring surgery. Gastroenterology trainees are also at risk, with 20% of surveyed fellows endorsing overuse injury, some even requiring work-related leaves of absence. In the early stages of ERI, aching and tiredness occur during the work shift only. In the intermediate stage, aching and tiredness occur early in the work shift and persist at night, and may be associated with a reduced capacity for repetitive work. In the late stages, aching, fatigue and weakness persist at rest and may be associated with inability to sleep and to perform light duties. Pain is an important signal indicating mitigation measures are required to control exposures.
Utilize the hierarchy of controls
The responsibility for adoption of ergonomically friendly practices does not lie solely with the physician; both institutional and industry-level support are key to its success. The hierarchy of controls defines which actions will best mitigate exposures to hazards in the workplace, highlighting that modifications to personal practice have the smallest impact. Current endoscope design does not accommodate the full range of hand strengths and sizes and contributes to ERI.
Advancements at the industry level by eliminating or substituting hazards, or designing engineering controls to reduce exposure, will be most effective at preventing distal upper extremity ERI. The next most effective controls are at the institutional level, with endoscopy units ensuring access to engineering controls and implementing effective administrative controls. For example, institutional support and investment in adjustable workstations is imperative to accommodate a range of anthropometric dimensions of the population. Support for ergonomic education, scheduling changes and a culture where safety is a priority can help reduce exposure to hazards and injury risk.
Adjust the endoscopy suite to achieve a comfortable position before every procedure
Neutral body posture is our position of greatest comfort and maximum strength, and any deviation from neutral posture decreases the amount of force the muscles can produce and causes the muscles to fatigue sooner. The most important factor affecting the endoscopists’ overall posture is the monitor position and height. Monitors must be adjustable. Place the monitor directly in front of you, with the center of the screen 15-25 degrees below eye height for a neutral neck position and resting eye position. Procedure bed height should be adjusted 0-10 cm below elbow height to allow for neutral elbow postures and relaxed shoulders. Antifatigue mats and shoes with supportive insoles can reduce fatigue. Two-piece lead aprons distribute a portion of the static load to the hips and decrease back strain. Incorporate a preprocedure ergonomic time-out, to assess proper room set up, body mechanics, equipment and team preparedness.
Give yourself a break
Breaks should be built into the endoscopy schedule, especially for a full day of endoscopy. At a minimum, incorporate microbreaks during procedures, which have been found to alleviate pain and improve performance. Exercises and stretching can be incorporated between cases, including routines designed specifically for endoscopists.
Getting older isn’t for the weak
Currently, 50% of our gastroenterologists are over 55 years old. The aging process leads to a distinct muscle mass and strength loss. Women are already at a disadvantage because, on average, they have less muscle mass than men in all age groups. Muscle starts to deteriorate when we reach our 30s, and after age 40, we lose on average 8% of our muscle mass every decade which accelerates at an even faster rate after age 60. Both resistance and aerobic exercise can be very useful to counteract sarcopenia and maintain strength. Given the physical demands of endoscopy, exercise can help safeguard career longevity and maintain overall wellness. Multiple resources are available to tailor a program that fits your time, budget and needs.
Optimize all of your workstations
Prolonged computer use and desk work is also a significant part of a gastroenterologist’s profession. If using a sitting desk, chair height should allow for 90-degree flexion at the hips and knees and for feet to rest flatly on the floor. The chair should also provide adequate back support for a relaxed upright position. Similar to endoscopy, place the monitor directly in front with the center of the screen slightly below eye level. For mouse and keyboard placement, aim to have the elbows at or slightly below 90 degrees and one’s wrists and fingers in neutral position.
Endoscopy can be hazardous to the endoscopists’ health. Incorporating ergonomic principles creates a safer and more efficient work environment. At the individual level, ergonomically optimized postures during endoscopy as well as during computer-related tasks, room set up, inclusion of microbreaks, and protective exercises can help decrease the risk of repetitive strain injury and prevent disability. Importantly, change at the industry and institutional level has the greatest potential for positive impact. Adoption of ergonomic practices promotes career longevity and ensures that gastroenterologists can continue successful and long careers and provide quality care to their patients without compromising their own health.
Dr. Lipowska is an assistant professor in the division of gastroenterology and hepatology, University of Illinois at Chicago. She disclosed no conflicts. Dr. Shergill is chief of gastroenterology for the San Francisco VA Health Care System. She disclosed consulting work for Boston Scientific and Neptune Medical, honoraria for visiting professorship with Intuitive Surgical, and a research gift from Pentax.
References
Shergill AK. Top tips for implementing an endoscopy ergonomics program. Gastrointest Endosc. 2023 Feb;97(2):361-4.
Pawa S et al. Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey. Am J Gastroenterol. 2021;116(3):530-8.
Austin K et al. Musculoskeletal injuries are commonly reported among gastroenterology trainees: Results of a national survey. Dig Dis Sci. 2019;64(6):1439-47.
Lipowska A et al. Ergonomics in the unit: Modeling the environment around the endoscopist. Tech Innov Gastrointest Endosc. 2021;23(3):256-62.
Park A et al. Intraoperative “Micro Breaks” with a targeted stretching enhance surgeon physical function and mental focus: A multicenter cohort study. Ann Surg. 2017;265(2):340-6.
Shergill A et al. Ergonomic endoscopy: An oxymoron or realistic goal? Gastrointest Endosc. 2019;90(6):966-70.
Dear colleagues,
We are all part of one of the most exciting and varied fields of medicine and hope to have long and productive careers. In this month’s AGA Perspectives we explore two different impediments to longevity as a gastroenterologist: work-related disability and burnout.
Physician burnout has reached almost epidemic levels in medicine and is best approached in a multimodal manner, incorporating both institutional and individual changes. Dr. Sumeet Tewani discusses ways in which groups and institutions can foster physician wellness to reduce burnout. In particular, he will explore how flexibility in work schedules, among other initiatives, can improve workplace morale. In an accompanying perspective, Dr. Anna Lipowska and Dr. Amandeep Shergill explore how to incorporate ergonomics in endoscopy to prevent injury. Endoscopic practice, with its repetitive tasks and physical demands, can predispose to injury at all levels of training and experience. Ergonomics is thus a critical topic that is unfortunately covered too little, if at all, in our endoscopy training.
We hope these essays will help your medical practice and welcome your thoughts on these important issues at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Fostering physician wellness to prevent burnout
BY SUMEET TEWANI, MD
Gastroenterology can be a challenging field, both professionally and personally, as it requires providers to have high clinical knowledge, expertise, and emotional intelligence. Burnout is a state of emotional, physical, and mental exhaustion, depersonalization, and a reduced sense of personal accomplishment, caused by prolonged or excessive stress. Burnout can be a serious and progressive chronic condition that negatively impacts the provider and patient experience, with serious consequences on the provider’s health, job performance, patient satisfaction, and personal relationships.
Adopting strategies to combat burnout are of vital importance to promoting provider wellness, a healthy work environment, and positive interactions with colleagues, staff, and patients. This also positively impacts providers’ out-of-work experiences and relationships. on an institutional level and on an individual level.
Multiple factors affecting burnout have been identified, including individual factors, work volume, professional risk and responsibility, resources, and relationships with colleagues and patients. Practicing gastroenterology frequently requires long and irregular work hours, heavy workloads, large panels of complex patients, invasive procedures, and high amounts of stress. Additional stressors may include an inefficient work environment, inadequate support, and loss of value and meaning in work. Nearly 50% of physicians meet criteria for burnout, citing such reasons as excessive bureaucratic tasks, lack of control, flexibility and autonomy, lack of peer respect, increasing computerization of practice, and lack of respect from patients.
Preventing burnout
When coping with burnout, many providers choose positive mechanisms such as exercise, listening to music, meditation, and talking with family and friends. Others become more isolated, eat junk food or binge eat, or turn to drug or alcohol abuse. Our primary approach to preventing burnout at an individual level is to ensure providers have access to self-care techniques such as stress management and mindfulness, and to encourage wellness with regular exercise and healthy habits. Promoting a culture of work-life balance requires providing adequate time for personal activities and hobbies, rest, relaxation, and spending time with family and friends. Allowing providers to personally shape their career paths aligns their personal and professional goals, leading to greater satisfaction. To this end, providers may become involved in clinical research, medical education, and clinical and administrative committees through the practice, local medical school and hospitals, and local and national societies. We provide ample vacation time and CME opportunities for our providers. Vacation time is flexible and can be taken in half-day or full-day increments, or on an hourly basis for personal time as necessary. This allows for enhanced flexibility with scheduling time off from work.
On an institutional level, leadership plays a prime role in creating a healthy work environment. Having good leaders influences the well-being and satisfaction of everyone within the organization. Leaders can have a positive impact by aligning values and work culture, using incentives in a productive manner, and promoting strategies to reduce burnout. Involving physician partners in leadership on a rotating basis allows them to better understand the roles of the leaders in the organization and empowers them to have a voice in changing policies to reduce administrative burdens and foster wellness.
We promote the concept of working together as a team for the success of the practice. All partners have an equal say in the management of the group. We eliminated the stress of competition within the group, equalizing pay across all physician partners, while maintaining equal exposure to work and equal time off from work. This levels the playing field between physicians who have varied interests and expertise, so that everyone is working towards the success of the practice and not individual compensation. To that end, our providers do not have individual offices, but work out of a “bullpen” with an open concept where we have individual workspaces and interact with each other continuously throughout the day. This promotes cohesion and teamwork between the providers for all our patients and promotes professional relationships and peer support. Efforts to promote workplace morale include access to a fully stocked deli and a newly installed espresso machine.
The concept of teamwork
The concept of teamwork also needs to pervade through the entire organization. To manage the demands of a busy workday, we have directly trained advanced practice nurses in the clinic and inpatient settings, allowing our physicians to increase throughput and procedures while maintaining a high level of patient care, satisfaction, and efficiency. Providers report excessive administrative tasks and frustration with the electronic health record as major factors contributing to burnout. Delegating tasks to staff, commensurate with their training and scope of practice, alleviates some of this burden. Each of the providers in our practice has a triage nurse who functions in a key capacity to ensure the appropriate clinical and administrative tasks are complete. Medical scribes, medical assistants, nurses, and physician assistants can be utilized for data entry and other tasks. We have developed templates within the electronic health record that can be standardized across the practice. Promoting teamwork with staff also means respecting the staff and understanding their needs. A highly functioning health care team can provide comprehensive care proactively and efficiently, with improved professional satisfaction.
In summary, I identify several ways to promote physician wellness. Every GI practice should strive to implement local approaches to prevent physician burnout and help maintain a happy and productive workforce.
Dr. Tewani is a gastroenterologist with Rockford Gastroenterology Associates in Rockford, Ill. He has no relevant disclosures.
References
1. Koval ML. Medscape gastroenterologist lifestyle, happiness & burnout report 2023: Contentment amid stress. Medscape. 24 Feb 2023.
2. Ong J et al. The prevalence of burnout, risk factors, and job-related stressors in gastroenterologists: A systematic review. J Gastroenterol Hepatol. 2021 Sep;36(9):2338-48.
3. Anderson J et al. Strategies to combat physician burnout in gastroenterology. Am J Gastroenterol. 2017 Sep;112(9):1356-9.
4. Keswani R et al. Burnout in gastroenterologists and how to prevent it. Gastroenterology. 2014 Jul;147(1):11-4.
The hazards of endoscopy: Ergonomics guide the way
BY ANNA LIPOWSKA, MD, AND AMANDEEP SHERGILL, MD, MS
Preventing disability and promoting a long and successful endoscopic career involves proactive measures to support well-being, and ergonomics plays a key role. Ergonomics is the science of fitting a job to the worker, with a primary goal of working smarter and safer. When hazards are identified, mitigation measures, guided by a hierarchy of controls, must be implemented that improve the fit of the tool, task and job to the worker in order to reduce the risk of endoscopy-related injury (ERI). As more women enter the field and as the overall GI physician population ages, ensuring that endoscopy is designed to be safely performed within the capacity of a diverse group of workers will be critical to creating an inclusive and equitable work environment.
Ergonomic education is foundational: Awareness of ERI risk factors allows endoscopists to identify hazards and advocate for effective control solutions. Ergonomic education materials are available through all of the major GI societies. A road map for implementing an endoscopy ergonomics program has been previously published and provides guidance on risk assessment and mitigation measures.
Respect pain
Overuse injuries occur when the physical demands of a job are greater than tissue tolerances, leading to cumulative microtrauma. The first sign of microtraumatic injury is discomfort and pain. Studies have demonstrated that an estimated three-quarters of gastroenterologists experience ERI, with 20% requiring time off work and 12% requiring surgery. Gastroenterology trainees are also at risk, with 20% of surveyed fellows endorsing overuse injury, some even requiring work-related leaves of absence. In the early stages of ERI, aching and tiredness occur during the work shift only. In the intermediate stage, aching and tiredness occur early in the work shift and persist at night, and may be associated with a reduced capacity for repetitive work. In the late stages, aching, fatigue and weakness persist at rest and may be associated with inability to sleep and to perform light duties. Pain is an important signal indicating mitigation measures are required to control exposures.
Utilize the hierarchy of controls
The responsibility for adoption of ergonomically friendly practices does not lie solely with the physician; both institutional and industry-level support are key to its success. The hierarchy of controls defines which actions will best mitigate exposures to hazards in the workplace, highlighting that modifications to personal practice have the smallest impact. Current endoscope design does not accommodate the full range of hand strengths and sizes and contributes to ERI.
Advancements at the industry level by eliminating or substituting hazards, or designing engineering controls to reduce exposure, will be most effective at preventing distal upper extremity ERI. The next most effective controls are at the institutional level, with endoscopy units ensuring access to engineering controls and implementing effective administrative controls. For example, institutional support and investment in adjustable workstations is imperative to accommodate a range of anthropometric dimensions of the population. Support for ergonomic education, scheduling changes and a culture where safety is a priority can help reduce exposure to hazards and injury risk.
Adjust the endoscopy suite to achieve a comfortable position before every procedure
Neutral body posture is our position of greatest comfort and maximum strength, and any deviation from neutral posture decreases the amount of force the muscles can produce and causes the muscles to fatigue sooner. The most important factor affecting the endoscopists’ overall posture is the monitor position and height. Monitors must be adjustable. Place the monitor directly in front of you, with the center of the screen 15-25 degrees below eye height for a neutral neck position and resting eye position. Procedure bed height should be adjusted 0-10 cm below elbow height to allow for neutral elbow postures and relaxed shoulders. Antifatigue mats and shoes with supportive insoles can reduce fatigue. Two-piece lead aprons distribute a portion of the static load to the hips and decrease back strain. Incorporate a preprocedure ergonomic time-out, to assess proper room set up, body mechanics, equipment and team preparedness.
Give yourself a break
Breaks should be built into the endoscopy schedule, especially for a full day of endoscopy. At a minimum, incorporate microbreaks during procedures, which have been found to alleviate pain and improve performance. Exercises and stretching can be incorporated between cases, including routines designed specifically for endoscopists.
Getting older isn’t for the weak
Currently, 50% of our gastroenterologists are over 55 years old. The aging process leads to a distinct muscle mass and strength loss. Women are already at a disadvantage because, on average, they have less muscle mass than men in all age groups. Muscle starts to deteriorate when we reach our 30s, and after age 40, we lose on average 8% of our muscle mass every decade which accelerates at an even faster rate after age 60. Both resistance and aerobic exercise can be very useful to counteract sarcopenia and maintain strength. Given the physical demands of endoscopy, exercise can help safeguard career longevity and maintain overall wellness. Multiple resources are available to tailor a program that fits your time, budget and needs.
Optimize all of your workstations
Prolonged computer use and desk work is also a significant part of a gastroenterologist’s profession. If using a sitting desk, chair height should allow for 90-degree flexion at the hips and knees and for feet to rest flatly on the floor. The chair should also provide adequate back support for a relaxed upright position. Similar to endoscopy, place the monitor directly in front with the center of the screen slightly below eye level. For mouse and keyboard placement, aim to have the elbows at or slightly below 90 degrees and one’s wrists and fingers in neutral position.
Endoscopy can be hazardous to the endoscopists’ health. Incorporating ergonomic principles creates a safer and more efficient work environment. At the individual level, ergonomically optimized postures during endoscopy as well as during computer-related tasks, room set up, inclusion of microbreaks, and protective exercises can help decrease the risk of repetitive strain injury and prevent disability. Importantly, change at the industry and institutional level has the greatest potential for positive impact. Adoption of ergonomic practices promotes career longevity and ensures that gastroenterologists can continue successful and long careers and provide quality care to their patients without compromising their own health.
Dr. Lipowska is an assistant professor in the division of gastroenterology and hepatology, University of Illinois at Chicago. She disclosed no conflicts. Dr. Shergill is chief of gastroenterology for the San Francisco VA Health Care System. She disclosed consulting work for Boston Scientific and Neptune Medical, honoraria for visiting professorship with Intuitive Surgical, and a research gift from Pentax.
References
Shergill AK. Top tips for implementing an endoscopy ergonomics program. Gastrointest Endosc. 2023 Feb;97(2):361-4.
Pawa S et al. Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey. Am J Gastroenterol. 2021;116(3):530-8.
Austin K et al. Musculoskeletal injuries are commonly reported among gastroenterology trainees: Results of a national survey. Dig Dis Sci. 2019;64(6):1439-47.
Lipowska A et al. Ergonomics in the unit: Modeling the environment around the endoscopist. Tech Innov Gastrointest Endosc. 2021;23(3):256-62.
Park A et al. Intraoperative “Micro Breaks” with a targeted stretching enhance surgeon physical function and mental focus: A multicenter cohort study. Ann Surg. 2017;265(2):340-6.
Shergill A et al. Ergonomic endoscopy: An oxymoron or realistic goal? Gastrointest Endosc. 2019;90(6):966-70.