Physician Wellness & Its Impact on Patient Safety

AAO Ergonomics Symposium AAO Ergonomics Task Force Presenters Jeffrey L. Marx, MD Scott Olitsky, MD Jeremy Wehking, PT, OCS, FAAOMPT, PRC Financial Disclosure

The presenters do not have any financial interests or relationships to disclose. AAO Ergonomics Task Force Members

Jeffrey Marx MD, Chair Keith Baratz MD Anna Kitzmann MD

Thomas Liesegang MD Meher Yepremyan MD Martin Wand MD George Bartley MD, Tamara Fountain MD and Ruth Williams MD, ex-officio Jane Aguire and Jill Hartle, AAO staff

Ergonomics Ergonomics, as defined by the Board of Certification for Professional Ergonomists (BCPE), "is a body of knowledge about human abilities, human limitations and human characteristics that are relevant to design. Ergonomic design is the application of this body of knowledge to the design of tools, machines, systems, tasks, jobs, and environments for

safe, comfortable and effective human use" (BCPE, 1993). Greek Ergos = Work Greek Nomos = Study of Common Acronyms

MSD = Musculoskeletal Disorder CTD = Cumulative Trauma Disorder RSI = Repetitive Strain Injury WMSD = Work Related Musculoskeletal Disorders All refer to wear and tear on the body over time that can lead to an injury Incidence of MSDs in Ophthalmologists

Recent Evidence Prevalence of MSDs in Ophthalmologists Survey of 697 ophthalmologists in northeastern US

Self-reported neck, upper extremity or lower back symptoms in prior month was 52% Lower back pain: 39% Upper extremity pain: 33% Neck pain: 33% 15% were slightly to moderately limited in their work as a result of these symptoms

Dhimitri KC et al. Symptoms of musculoskeletal disorders in ophthalmologists. Am J Ophthalmol 2005; 139:179-81. Prevalence of MSDs in Ophthalmologists Neck Pain Associated with: >100 encounters/week

>6 lasers/week >4 surgeries/week Back Pain Associated with: >6 lasers/week Job stress

Upper Extremity Pain Associated with: Female gender Dhimitri KC et al. Symptoms of musculoskeletal disorders in ophthalmologists. Am J Ophthalmol 2005; 139:179-81 Risk of MSDs in Other Industries Based upon Gender Musculoskeletal Disorders, particularly those of the upper body are seen across many industries- both health care and non-health care.

Employed women are 2 to 5 times more likely than men to report MSD problems Prevailing explanations of womens excess health risk revolve around 2 basic propositions Work Family Model- Higher demands and constraints that women face or women are more affected/vulnerable to health impact of particular demands/constraints. May be affected by accumulation of differences in exposures at work and at home. Vulnerability Model- Sex linked biological factors such as hormones or physiology

Prevalence of MSDs in Ophthalmologists Potential Relationships of Female Ophthalmologists increased prevalence of MSDs and Vulnerability Model Women were more likely to report neck pain, upper extremity pain and weakness despite seeing fewer patients and performing fewer procedures per week Shorter stature

Shorter arms/reach Clothing necessitates accommodation at slit lamp Dhimitri KC et al. Symptoms of musculoskeletal disorders in ophthalmologists. Am J Ophthalmol 2005; 139:179-81 Prevalence of MSDs

Survey of ophthalmologists and family medicine doctors at University of Iowa and Mayo Clinic 186 surveys completed by 94 ophthalmologists and 92 family medicine doctors Symptom quality and severity during 30 day period prior to questionnaire Kitzmann et al. A survey study of musculoskeletal disorders among eye care physicians compared to family medicine physicians. Ophthalmology, February 2012. Prevalence of MSDs

Neck Pain 46% ophthalmologists vs. 21% family medicine doctors Hand/Wrist Pain

17% ophthalmologists vs. 7% family medicine doctors Lower Back Pain 26% ophthalmologists vs. 9% family medicine doctors Kitzmann et al. A survey study of musculoskeletal disorders among eye care physicians compared to family medicine physicians. Ophthalmology February 2012 Incidence of MSDs

It is anticipated that the number of overuse injuries will increase with: Increasing demand for services Increasing age of practitioners What are the costs of these injuries both professionally and personally? Loss of work days? Loss of income? Affects leisure activities?

Activity Factors Awkward Postures

Repetitive Motions Long Durations High Forces Environmental Vibration Cold or Heat

Why Not Everyone? Similar Activity Factors with Different Results Why? Personal Factors

Age Gender Height/Weight Ratio Hobbies Computer Use (at home)

Sports Yard Work Exercise/activity level Smoking Site Observations: Clinic Exposures

Opportunities for Improvement Now! Site Observations: The Clinic Reviewing Patient Information C-Spine Awkward neck and back posture

Site Observations: The Clinic Reviewing Patient Information Site Observations: The Clinic Positioning for General Exam For appropriate patients, consider the use of a foam back wedge that will decrease how far a patient is

from the front of the seat edge. Have patient move or lean forward so you do not have to lean forward Site Observations: The Clinic Positioning for General Exam Custom SL table with less deep top

and with sloping edge (Keith Baratz) Site Observations: The Clinic Using the Slit Lamp Adjust the oculars to assist or consider after market oculars

Site Observations: The Clinic Using the Slit Lamp Site Observations: The Clinic Using the Slit Lamp: Wrist Postures Site Observations: The Clinic Using the Slit Lamp: Pinching Condensing Lens

Site Observations: The Clinic Indirect Ophthalmoscopy Site Observations: The Clinic Indirect Ophthalmoscopy OUCH!! Site Observations: The Clinic

Giving Injections Site Observations: The Clinic Giving Injections Site Observations: The Clinic Giving Injections: The Sharps Container Site Observations: The Clinic

Support Staff Tasks: Talk to the Staff Sharps container located underneath the sink causing awkward postures Searching for supplies in low drawers. Consider a 5S initiative to standardize the location of items to reduce searching. Label locations. New room designs can have supply drawers located from thigh to mid chest height to reduce bending

Site Observations: The Clinic Support Staff Tasks Office Ergonomics: Typical Exposures and Better Postures Do not cradle your phone Site Observations: Operating Room

Exposures Opportunities for Improvement In the Operating Room Cranking bed Awkward Posture In the Operating Room Electric bed positioning eliminates some of

the manual lifting/lowering patients In the Operating Room Draping and preparing the patient Physician has his back bent forward

and arms abducted Raising height of bed would reduce this posture In the Operating Room

Retro/Peribulbar injections The physicians back is bent forward and held in this position for some period of time. Raising the bed would help reduce this awkward posture In the Operating Room

Back and neck position while using microscope is critical In this picture, the physicians neck is in extension. The eyepieces need to be set

slightly below sitting eye height In the Operating Room Sustained shoulder retraction

Holding shoulders in this position provides stability, but stresses trapezius muscle and may lead to shoulder and back pain. Armrests on stools or wrist rests can provide support for forearms In the Operating Room

Slide upper left: Flexed kyphotic neck and back without use of lumbar support Slide upper right: Neutral position with proper use of back support. In the Operating Room

Back tilted due to different height profiles of the foot pedals. Raising the microscope foot pedal slightly with towels could place the feet at a similar height and reduce tilting of trunk

Using Towels underneath can also assist with positioning the food pedals In the Operating Room Upper left: Flexed/kyphotic neck and back with microscope positioned vertically

Upper right: Neutral spinal curvature and reduced musculoskeletal workload with the microscope tilted to accommodate a more neutral posture In the Operating Room

Prolonged precision gripping of instruments Attempt to be as relaxed as possible while gripping instruments for prolonged periods Periodically pause and stretch upper extremities with at least a

finger flexor and a finger fan stretch. When possible, pause, stand and perform a low back stretch Final Thoughts Good ergonomic practices need to be utilized early in life both in your personal and professional life Results will be slow, but benefits will be life-long.

Dutch Dental Society instituted ergonomic recommendations: 50% dentists adopted all or most and 40% more adopted some of the recommendations; 72% had decreased or total resolution of their main MSD complaint. Dreoze & Jonsson, Work 2005

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