As a neurosurgeon, I once cared for a pharmacist suffering from debilitating arm pain and weakness. Her neck failed after two of her discs ruptured, compressing her spinal nerves. She explained to me that her employer, a major retail pharmacy chain, had barcoded her arm so they could more closely monitor her productivity: how many prescriptions she filled per hour, how long she spoke on the phone.
She worked under these constraints until her already-painful neck condition became intolerable. The pace, scrutiny, and drive for robotic efficiency were neither healthy nor sustainable. After I resolved her neck issues, she quit her job.
Healthcare organizations, including hospitals and pharmacies, are increasingly structured around productivity and efficiency. Physician pay is often based on the number of procedures done and patients seen. The sense of duty and calling of practitioners is baked into health systems’ expectations of maximum productivity from their employees.(1)
CASUALTIES OF PRODUCTIVITY
I built a career as a maximally efficient neurosurgeon. For more than 30 years, I worked tirelessly, modeling myself on the physicians under whom I trained: surgeons who arrived at the hospital before dawn and left each evening well after dark. These behaviors reflected the prevailing values of American medicine’s workplace culture.
I dismissed the signs of approaching catastrophic failure in my own body, working through increasingly disruptive elbow pain with breaks and vacations and periodic rest until I could no longer ignore the pain in my arm. I was unable to straighten my arm, grip, or perform the precise, yet forceful, moves of neurosurgery.
Only after months away, and after my own surgery, am I starting to understand what happened. I discovered something never discussed in my training: Workplace injuries among surgeons are shockingly common and vastly underreported.(2)
Physicians focus on patient comfort and safety, carefully positioning anesthetized patients to protect their bodies but never considering our own, despite performing repetitive surgical maneuvers for 10 or more hours per day.
We wear equipment, such as headlights and magnifying lenses, to facilitate these procedures, or protective equipment to avoid radiation exposure. This equipment shifts our postures forward, adding stress to our spines and joints. Laparoscopic surgeries place us in awkward positions, contributing to injuries.(3)
Women are often disadvantaged in the operating room, as gripping and biting tools are typically manufactured in one size only, despite differing hand sizes among surgeons. This results in increased repetitive stress and injuries,(4) as tools may be used more than 100 times during a single surgery.
All of these experiences contort surgeons’ bodies, increasing stress on joints such as elbows, wrists, and shoulders, and making them prone to injury.(5)
Ergonomics, the study of people in their work environment,(6) is a focus of industrial processes, but rarely an explicit consideration in operating rooms. Making ergonomics a focus in the operating room goes a long way toward preventing injuries among surgeons, as can stretches, exercises, and mini-breaks during lengthy surgeries.(7) These activities can interrupt the pattern of trauma, muscle imbalance, and compensatory movement patterns which, unchecked, can lead to injury.(8)
Some adaptive options are available, such as tools designed around physician safety, but health systems may be reluctant to pay for them, citing cost concerns. Many surgeons face highly contentious procurement processes to gain approval for new tools and equipment. I have experienced this on numerous occasions, where the burden to justify effectiveness and expense is placed largely on surgeons themselves.
LITERATURE REVIEW OF OPERATING ROOM INJURY AND PREVENTION
Surgeon workplace injury is far more common and more underreported than most realize. Schlussel, et al.(9), observe that more than 80% of surgeons have work-related injuries; the focus in surgical procedures is on the patient, with little concern for the surgeon’s posture or spinal stability. They note that surgeons ignore and rarely report symptoms.
The range of surgeon injuries spans many surgical disciplines, including laparoscopy, microsurgery, cardiac surgery, orthopedics, OB/GYN, and robotic surgery. The types of injuries are reflective of the types of surgeries performed. For example, robotic surgeries lead to activation and pain in neck musculature due to prolonged time spent sitting at a monitor.(10) Dentists and general surgeons report elevated levels of workplace injury.(6,9,11,12)
Much of the research on surgeon injury in the workplace comes from orthopedics publications; fewer published research comes from the area of neurosurgery. Still, the available literature strikes a similar tone.
Xu, et al.(5), published an extensive review of surgeon injuries in orthopedics. They reviewed 26 studies, noting a wide range of responses and quality among the studies. Prevalence of injuries was as high as 97%, with the greatest number of complaints related to low back, hip/thigh, neck, and upper extremity pain and injuries. The bulk of these injuries (27%–66%) were managed non-operatively. Between 5% and 31% of surgeons took time off work. Surgical treatment occurred in 3% to 34%. A full 59% of surgeons changed their plans because of their injuries. This included changing their practices or opting for early retirement.
One review article from the neurosurgery literature(13) describes frequent injuries in spine surgeons due to prolonged neck flexion and neglected posture. Low back pain was present in 62%, with 31% of surgeons experiencing ruptured lumbar discs. Their 23% surgery rate is higher than that of the general population. Neck pain and injury occur in 59% of respondents, shoulder in 49%, finger in 31%, and wrist in 25%. There was a linear increase in the rate of carpal tunnel syndrome with the hours of spinal surgery performed. Performing cranial surgery was associated with higher rates of neck and shoulder injuries, particularly with endoscopy.
These review articles suggest the causes of surgeon injuries as well as ways to prevent them. Xu, et al.(5), provide suggestions for preventing injuries, including improving operating posture by adjusting surgical field height, lightweight lead limiting forward postural loading, and the use of microscopes over loupes, which also decreases prolonged forward flexion. They also suggest reducing upper extremity exertion and fatigue with ergonomic design and power tools and preventing discomfort with attention to footwear and padding, use of compression stockings, microbreaks, and stretching.
Additional recommendations include increasing surgeons’ awareness of ergonomic recommendations — currently only 9% of surgeons are aware of these recommendations and only 3% apply them in their practices. Xu and colleagues also recommend postural ergonomics (PT assessment), innovations in equipment design, schedule adaptation, mini-breaks, and specific preventative exercise programs.
Allan Mishra, MD, clinical associate professor of orthopedic surgery at Stanford University, describes his experience: “I screamed in agony as I completed a routine knee surgery. I had twisted my back while holding a large leg and immediately felt searing pain shoot down my right leg to the top of my foot. It felt like someone had dunked my leg in boiling oil. In an instant, I went from being a surgeon to needing surgery.”
Mishra underwent a lumbar microdiscectomy by an orthopedic spine surgeon colleague, requiring six weeks out of work, from which he fully recovered. Nine years later, he ruptured a disc in his neck. This required surgical intervention and time off work (also fortunately resulting in full recovery) because of sudden and profound arm weakness.
DO INJURIES REFLECT INDIVIDUAL OR SYSTEM FAILURES?
In her book The Burnout Challenge,(14) written with Michael P. Leiter, Christina Maslach illustrates the concept of burnout correction with the metaphor of the canary in the coal mine. The canary is in the mine to let everyone know when noxious gases put miners at risk. In medicine, our current model of corrective action is to identify canaries at risk of failure rather than fix the mine itself. Maslach, creator of the Maslach Burnout Inventory,(15) observes that healthcare wants to build stronger, more resilient canaries, not to correct the work environment that injures the canaries in the first place.
Physical injury in the operating room is an illustration of the gulf between the perspectives of practitioners and those of health systems. It also provides a path toward a collaborative solution. Through education, workplace and equipment redesign, and implementation of ergonomic principles and preventive solutions, many surgeons can avoid injuries.
Rather than focusing on maximizing productivity and efficiency, healthcare could support surgeons and prevent injuries — fixing the mine rather than the canary. To do so, workplace culture among surgeons also needs to change. We are taught to ignore our own discomfort, focusing only on our patients. We rarely complain or even report injuries, mistakenly seeing this as a sign of weakness.
The dental industry, acknowledging high rates of injury among practitioners, has made strides toward preventing common workplace injuries(11) with routine sitting and operatory redesign.(12) Costs of improvement are offset by less time out to recover from injuries and longer, healthier, satisfying careers. Helping healers heal increases loyalty and satisfaction from surgeons who feel supported rather than ignored or exploited.
At the Burnout Symposium in Los Angeles in February 2023, Maslach explained that people are misusing her inventory, reshaping her work to fill their own needs.(16) She says they are assessing individuals as burned out, or at risk of burning out, and then trying to patch them — as if the individuals are the ones with a problem. This incorporates both blaming and shaming and only adds to the crisis.
Maslach explained that burnout is not a mental health condition, but is, at its root, a normal reaction to unmitigated chronic workplace stress. It takes an emotional and a physical toll. The only way to fix it is not by “fixing” individuals, but by fixing the systems that are causing injury and burnout.
RAISING AWARENESS
While redesign is important in operating rooms, these principles apply throughout medical systems. A third of physicians spend more than 20 hours a week charting and performing administrative tasks(17) largely in the electronic health record (EHR). While burnout is associated with unlimited paperwork and EHR tasks, a medical student shared with me his thoughts about the latest modules in Epic, a widely used electronic medical record, that monitor a user’s keystrokes and could therefore be used to assess the user’s efficiency and productivity.
The medical student initially was enthusiastic about this “innovation.” On closer questioning, however, he became concerned. Not only did this innovation represent a disturbing level of scrutiny, as it did for the closely surveilled pharmacist mentioned earlier, but also the medical student knew that his doctoring takes place outside of the EHR, with his patients. The most valued, most human things he does cannot be measured by the efficiency of his keystrokes. This represents a distraction from and disregard for human connections and priorities.
As consumers of healthcare, we value pharmacists who address our concerns and doctors who not only examine, but speak with us as well. The services we value most aren’t measurable with a barcode reader or keystroke-tracking modules. As providers of healthcare, our most informative and meaningful interactions with patients — listening to them or touching them — necessarily take time and are inherently “inefficient.” The EHR cannot capture these interactions.
Health systems must align with providers to provide humane, often hard to measure compassionate care, rather than focusing entirely on metric-driven productivity and revenue generation. This must be done with intentionality and properly devised incentive structures, partnering leaders with providers to support achieving these goals. This will not occur on its own.
Healthcare organizations are generally geared to immediate risk and injuries tied to specific events, but they are often unaware of, or unwilling to accept, their roles in longer-term exposure or the costs of mitigating those risks. This approach ties into the focus on individual patients and the risks to the patient inherent in each episode of treatment. There is little awareness of the cumulative risk over time to the treatment team that is performing surgeries on a high-volume basis.
An analogy can be found in radiation safety. The operative team is at risk of injury due to radiation exposure (far greater risk than to an individual patient), but this risk is generally spread over time and can’t be tied to one exposure during a surgical procedure. Since risk assessment and mitigation are geared to specific surgeries, these long-term risks are often ignored. It is almost impossible to trace a dangerous level of radiation exposure to a specific surgery, although the cumulative risk is not in doubt.
Similarly, rates of injury to surgeons increase with specific procedures and the volume of surgeries performed. I found that efforts to decrease radiation risk to the surgical team were often met with resistance — resistance to acknowledging the extent of the problem or unwillingness to spend money to buy equipment that would address these safety concerns that, while real, were in the future.
Organizational reluctance to acknowledge these concerns and spend money to mitigate risk directly contributes to a sense of alienation among surgeons, who view this reluctance as a clear example of indifference to their wellbeing and as promotion of short-term institutional financial interests over concerns for practitioners’ longer-term health and safety. This sense of alienation is a significant contributor to physician burnout.(18)
When individual surgeons, concerned about their own health and safety, try to effect change against a backdrop of a lack of awareness, these concerns are often minimized or dismissed. Only with broader awareness of these risks, established mechanisms for addressing them, and cultures of mutual concern and support will the health and safety of surgeons be promoted.
Ultimately, these safety concerns directly impact the safety of patients, adherence to organizational mission, and surgeon wellbeing and longevity. Prioritizing health and safety concerns and supporting surgeons sends a powerful message of solidarity that is well worth the financial investment.
SOLUTIONS THROUGH INNOVATION AND COLLABORATION
Ergonomics must become a focus of surgical education and practice. This education should occur early in surgical training programs to raise awareness and prioritize corrective action. Current models of surgeon education emphasize self-sacrifice and selflessness. As a result, few trainees mention their own physical discomfort when performing surgery. Surgeons also tend to suffer in isolation, keeping their injuries to themselves far longer than is healthy. Older surgeons don’t want to admit their bodies aren’t cooperating, while younger surgeons, desperate to fit in, rarely complain. Change will come only when these issues are addressed more openly and when surgeons feel comfortable voicing their concerns and speaking with a collective voice.
We can increase awareness by inviting ergonomic assessments into the operating room, encouraging earlier assessment of surgeons by PT and OT to teach restorative exercises, developing surgical tools that better meet the needs of individual surgeons, and developing advocacy for change.
An example from the Department of Neurosurgery at the University of Michigan illustrates these problems. A woman trainee told me that despite the fact that the tools she must use in surgery don’t fit her hands, she never felt comfortable complaining and felt it was her duty to press ahead. In fact, the department’s six female residents approached one of the instrument manufacturer’s representatives to figure out if instruments could be modified for surgeons with smaller hands. The representative did not explore the possibility.
Maybe six residents didn’t seem like an adequate number. But, in reality, this problem affects many female surgeons and, ultimately, all surgeons. Surgeons coming together and insisting that properly fitting instruments be available to all would have tremendous leverage.
Increased awareness also requires cooperation with health systems, which must be willing to purchase and stock ergonomically appropriate instrumentation. Ultimately, this is a concern that affects patient safety as well as a long-term investment in the health, wellbeing, and longevity of the medical staff. Surgeons leaving work for injuries due to ergonomic concerns, or worse, ending their careers prematurely, doesn’t make sense financially for health systems. Nor does it make sense for systems to ignore the negative impacts on surgeons’ wellbeing, including burnout, that result from not actively supporting them and addressing their needs.
Awareness of workplace risk for surgeons is possible through partnerships with organizations such as the Occupational Safety and Health Administration (OSHA) and the American College of Surgeons (ACS) to ensure that this issue receives the priority it deserves. Inviting these organizations to assess the work environment in the operating rooms is a step in the right direction. OSHA can force changes to promote safety. Accrediting agencies such as The Joint Commission and surgery professional associations and organizations such as the ACS must include work safety standards in their reviews and set standards for hospital performance. These standards should be promoted within specialty training programs.
For meaningful changes to occur in the practice of workplace safety, the attitudes of surgeons must undergo a profound cultural shift. Collective awareness, education, and action (risk mitigation and prevention) are paramount to ensuring the safety and well-being of surgeons going forward.
We cannot prioritize patients over practitioners, or vice versa; we must fully support both, humanizing processes instead of focusing on cost, productivity, and efficiency over safety and long-term comfort.
Disregarding the needs of physicians leads to burnout and physical injury. We do this routinely with healthcare providers (with surgeons especially) but wouldn’t begin to tolerate it if it affected the patients with whose care we have been entrusted.
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