Our next speaker is Dr. Patrick Young, who is coming to us from the Walter Reed National Military Medical Center in Bethesda, and will speak about ergonomics and endoscopy. Well, I'd like to start, as always, with gratitude. So thanks, Dr. Bucobo, Dr. Williams, and Dr. Patel for having me out here today to talk about something about which I am passionate, and hopefully you are as well. So these are my disclosures. And I can tell you that I'm used to saying controversial things, and so my first controversial thing I will say is that people have been doing stuff for a long time. And as long as people have been doing stuff, people have been telling them how to do it better, right? So this is a lithograph from the 1600s, which gives me flashbacks to elementary school. This is how it's better to hold a pen, one way than another way, right? I still don't think I've gotten this correct. So you'd think that as long as we've been doing this, that ergonomics would be a concept that we've had for a long, long time, but it turns out that it really only started as a formal discipline around the middle of the 20th century when they noticed in Great Britain that people were coming back from the war. They were going back to try and rebuild Britain, you know, moving the machines of industry forward. But they were getting injured doing that. And they said, well, you know, we can't have people who escape Hitler's war machine being destroyed by our machines of industry, right? So we've got to do better. So what is ergonomics? So it comes from two words, ergo meaning work, and then nomos meaning loss. So literally it's a law of work, but really it's about workplace design, specifically about optimizing the interface between the operator and the environment. And I know we were quoting a lot from Dr. Walsh in this last one. She wrote a nice article in the gastro clinics of North America last year saying that the environment should be adapted to the operator and not vice versa. And I think it's vice versa that we've been doing for a long time. So why do I care about this? Well, there's a lot of physical activity that I like to do. I like to ride my bike. I like to run with my friends, and I like to perform complicated endoscopic procedures. Now one day I may hang my shoes up, I may hang my scopes up, but I want to be the one who decides that. I don't want an injury to be the thing that drives me out. I had a mountain bike wreck a couple of years ago that took me out of scoping for seven weeks or so. I ended up sitting there and seeing IBS and clinic and nothing against people who see IBS and clinic all day, but as a therapeutic endoscopist, I decided that was not something that I wanted to be about. So how common are these? So that's why I care. Why should you? And we know, I think, by this point that they're very, very common. Most of this is based on survey data. In fact, this is a survey or a meta-analysis of those surveys that's being presented at the ACG meeting here in the next couple of days by Aziz Buran. Shows that around 62% of us will have a musculoskeletal injury at some point in our career, 50% of us by the time that we're done being fellows, essentially. And then if you're a therapeutic endoscopist, which I presume many in this group would be, you're 75% likely to have an endoscopic-related injury or an ERI sometime during your career. If you're a woman, you don't even have to be an interventional gastroenterologist and you get to that level of risk. And as you can tell by the poster that's outside, there are more and more women who are getting into the field of gastroenterology, which is great for us. It's great for our patients, maybe not so great for the gastroenterologists who are getting injured, right? So I think we need to do some things better. There's a trend toward increased injury in private practice. I have the good fortune of having fellows do some of my scoping, right? I'm not touching the scope 100% of the time as I try and train them. And so I have a little bit of a relief and rest from that. And then 13% of folks in our study required time off work. And I think in the meta-analysis that Dr. Pawa, who I see in the back there, and her colleagues did for the ASGE, it was actually 20% of time in their analysis. So it's a lot of time off work. The other thing is there's just not enough of us. So we've seen this trend coming for quite some time. So the New York Times published this in 2009, said there's going to be a gastroenterologist shortage forecast. We see here, this was in GI and endoscopy news a couple of years ago, that says these are the numbers we expect in 2025. And if you're fortunate enough to be where Dr. Shaw and Dr. Williams and I are, we have a plethora of gastroenterologists for your needs. If you're out there with Dr. May, she's got great job security because there's not so many, right? And if you ask endoscopists, which was done by GI and endoscopy news, what do you view as the top five threats to GI practice in the United States? One of those five was a lack of gastroenterologists. And so there's not that many of us. Those of us who are here need to be able to keep working, taking care of patients and doing the things that need to be done. So what type of injuries do we have? Neck and back are tied, actually, in our meta-analysis at 37%, followed shortly by hand and thumb at 34%, but really anywhere in that upper body chain is at risk. Why do these things occur? Some of these things are going to be obvious, and so I'm going to go over them fairly quickly. There are what we call general risk factors, which are not unique to endoscopy, and this includes things like repetitive motion. So whether that's moving a ham along an assembly line, you know, or us doing endoscopy, repetitive motions are bad for you. We don't get to move our joints through their full range of motion, right? We're relatively fixed. Sometimes to put a polyp at six o'clock and do that complicated resection, we have to hold what's an awkward position with a lot of torque for a longer period of time than would be optimal for us to do. We end up concentrating the force on a small part of our hand. So if you see your fellow grabbing a scope like he's climbing a rope or he or she is climbing a rope, we disabuse them of that being the right way to do it, right? We want fine motor control, but doing that puts these forces on a very small part of our hand, which increases our risk. And as we know from Emma Deepshergill's work, among others, these forces that we generate, particularly in the forearm compartments, exceed the American College of Government Industrial Hygienist's standards for risk level. And so something needs to change based on those. Endoscopy-specific risk factors, I think, are mostly intuitive, but I'll go over them here. Higher endoscopic volume, so the more you do, the more at risk you are. The longer you've been doing this, which may be a surrogate for age, obviously, is also a risk factor. If you wear lead routinely, particularly if you wear one-piece lead as opposed to the kilt and vest style, you're at increased risk, particularly of neck and back injury. Insufficient recovery time. I think many of us are trying to figure out how to do more with less time and not figure out how to give ourselves more rest, but we do need to think about how we can recover sufficiently. Gender, when I started giving these talks, it was sort of a question as to whether that was a risk factor. I think now the data are fairly clear that it is an independent risk factor, and I'll go over some of the how and why in later slides. And then it turns out if you have more female patients, particularly thin female patients, that increases your risk because of the forces required. And certain positions, even. There was an article that came out within the last year that shows that if you are routinely putting people on their right side, doing a right lateral decubitus, that that puts you in a negative ergonomic position relative to left lateral decubitus positioning. So there's a lot of different things that can be done. Hand size was a question that we got a lot. And I would say that, you know, it matters for some things. The data are still a little bit mixed on this. And we started off with really just surgical data to look at. And what the surgical literature would tell you is that if you have bigger hands, you have fewer injuries. And of course, that's not just hand injuries. This is really a surrogate marker for things like muscular strength and density, tendon strength and density, all that sort of stuff. If you looked at gender and hand size, what they found is that women doing laparoscopic surgery had a higher rate of injury than men did. But even when you matched them for hand size. So it wasn't just that they had smaller hands. It was that there was something else going on. If you look at the endoscopy data, we have more than we did over the last few years, but still not as much as I think we need or would like. I could tell you that if you have smaller hands, particularly somewhere in the six to six and a half glove size, that the amount of time you spend at or near what's called a maximum voluntary contraction, meaning squeezing as hard as you can on that left forearm is higher. There was a recent study showing that it takes you longer to insert the colonoscope if you have small hands. And also, trainees, when surveyed, feel like it takes them longer to learn endoscopic skills. And I think we've probably all seen this among our trainees, if they have particularly small hands. So where the cutoff is small and where that cutoff is, is not that well defined, honestly. How does gender matter? Well, hand size is part of it, but certainly it's not the only part. There is just a constitutive difference in strength. And while I'm giving you broad ranges, the average woman has around 50% of the amount of strength of the average man, you know, based on age and other factors like that. Differences in preferred grip styles. This is something which I think was recently published. I have the presentation data here, is that most men prefer having the umbilical cord inside the forearm when they're doing endoscopic procedures, whereas the majority of women prefer to have it outside the forearm. My contention is that that's because that allows the endoscope to rotate in such a way that it puts the control knobs in better reach of the thumb if you have smaller hands. And so that's my assertion. But again, that's conjecture. This is just a survey data. They also had a preference for the same gender teachers, and I can imagine this being true. I remember being with somebody who had very different hand sizes than I and had to sort of approach endoscopy different. And when I was first thinking about this, I had a hard time translating what I was doing to what she is doing. And so I can see this being beneficial, having like to like there. We know that female trainees prefer using dial extenders. Whether those have any actual benefit or not, again, is unclear. It hasn't been well studied. But there's a preference for that if you can if you can find them. And then there was at least one study that showed the lack of ergonomic adaptability of the scope may be a barrier for women who are considering a career in advanced endoscopy. So go back here for a second. So this is the largest survey that's been done. Again, this is Dr. Pawar through the Women's Committee of the ACG. And while in this particular study, they didn't show a difference in injury rate between men and women, they did show there was a vast difference in the types of injuries they got. So men were higher risk of lower back pain and almost everything else was more common in women. And then, of course, pregnancy is specific to gender here. And I'm going to talk specifically about it in the next slide. So there are some physiologic changes, which I will review for you just briefly here. There's a number of hormones that relax your ligaments. So relaxin and estrogen and progesterone all have that impact. You have fluid retention, which can occur sort of globally, but can also occur in things like the carpal tunnel and in other tunnels in your body and can compress nerves there. Your weight gain is asymmetric, right? So you get this forward shift of gravity, which puts excess stress on the back. And so you get these common issues, which are predictable based on the changes. Now, the question is, what do you do about that, right? We just had one of our fellows give birth who scoped throughout her pregnancy. So what are some of the things that helped her? Resting your abdomen on the bed as you get a little bit further along may be beneficial. Limiting your standing time to a couple of hours at a time. Wearing compression hose also. If you have specific problems for which there is a solution, like a brace, like carpal tunnel syndrome, that could be helpful. If you're wearing lead, which is perfectly fine and safe to do, wearing a lighter version of the lead. And then seated endoscopy may also be of some benefit. And then there are also adjuncts you can do, including footstools, supportive footwear, and then strengthening exercises to help protect your lower back. Globally, even for those of us who are not pregnant, there are really three categories of possible solutions for how we fix these. The first is environmental, and I'll just let you take a look at that and sort of imagine in your mind what might be fixed from this. Hopefully by the end of this talk, you can look at this and sort of circle the things that you would change if this were your endoscopy unit. The second is how do we make us and our team more resilient? And then the third, and I think this is really the answer, a little bit like Dr. Berzin was talking about, is disruptive technologies, right? I think ultimately we're going to need to change the way we do business, but I think that's going to be an iterative process. So we are very fortunate that the ASGE just published these guidelines in the October issue, and this kind of puts everything very neatly into one slide. The first is that people need to be trained. So congratulations, you're doing step one already, so thank you for coming. We're going to do that. We feel strongly about it, but there's not a lot of evidence of how this helps. We know from some data that Samir Grover did that it prevents regression, so you don't get worse if you get trained, as opposed to there's a tail-off that you get if you're not trained. Exactly how to train you is also a question. What is fairly clear, though, is step two here, which is making sure that everything is optimized for you individually, and so that your monitor is adjustable such that your gaze lands somewhere in the 15 to 25 degree range, and since most of you probably don't carry protractors in your unit, I'll tell you the way that I like to think about this is if I'm looking basically straight ahead, the top of the monitor should be at my eye level. That way, my natural gaze is going to fall to around mid-monitor, which is going to put the natural curve of my cervical spine in the right angle. That's just a really quick, rough gauge. Your arms should be roughly parallel to the floor or slightly lower than parallel to the floor. That's an easy way to think about that, and then if you can, if your infection control people don't go crazy, having a padded mat is a good idea. If they don't allow you to do that for whatever reason, having padded shoes that are resilient, I think, is also a good idea, and then in between these things, stretching, and we can talk a little bit about the particular type of stretching, is also important, and really, ultimately, I want you to think about yourself as an endoathlete, so I think a lot of us care for our patients, and we sort of neglect and even abuse ourselves, so I want you to stop doing that as much as possible. If you consider what an Olympian is like, so this is somebody who has taken years of their life to train to do a very specific skill, which few other people have. They've foregone social niceties that other people might be able to participate in, right? They've focused, and an injury can take them completely off of that platform, and so even though you may not view yourself like this now, this is you, every one of you, okay? So treat yourself that way. So what are some other things we might do? Well, I think getting some good feedback is an idea. So there was a nice study done by Dr. Hallback, not Hallback and colleagues, but Markwell and colleagues, that had physical therapists come and give personalized feedback based on observations of you endoscopically, as opposed to just giving you general health and fitness advice, and what they found is it was decreased pain for these folks versus general advice. And I know not everybody is going to have access to a physical therapist. Maybe you're in private practice and, you know, as opposed to a big academic practice like this was done in, but these could be in person. They could be virtual. Maybe you videotape yourself and they get shown to an expert at a later time. I think there's a lot of ways this nut could be cracked. Stretching is important. I won't belabor that. If you can go to this YouTube site or to ACG Universe, there's a whole list of stretches which are likely to be beneficial. And then it's also likely that a strengthening program is going to help. And there's an interesting product, and I'm not necessarily advocating this, but I'm just letting you know what I think the future holds. So this is something called ErgoGenius, which Bala Al-Kurdi developed. And you can see here, this is sort of an artificial intelligence program where you just take your iPhone or the equivalent and you have it watch you. It gives you a score up here in the upper right. This is called a Reba score. This is sort of a predictor of what your likelihood of injury is going to be. And then at the end, after it gives you your personalized assessment, it also tells you what sort of exercises you could do to make yourself more resistant to the type of injuries that you in particular are at risk for. So again, this is in beta testing. If you want to try it out, you can scan that. You can do this. Again, not an endorsement. We don't have great data on this. But I think something like this is where we're headed in the future because this would be accessible to everybody. What are some open questions in this? Well, seated colonoscopy, you know, I've heard a number of people who anecdotally feel like it helps. We do not have data on that. Knob extenders, again, a preference, no data. Scope support. So this is something, again, that Amandeep Shergill is investigating, you know, taking the weight off of that headpiece on the scope. You know, maybe that will be beneficial. I think certainly empowering your team to help you is going to be useful, right? So the things I'm telling you, go home and tell them, and then give them permission to critique you. Have them watch you and say, you know, I notice that I'm looking up a lot when I'm searching for polyps. You know, tell me to keep my head level. And then, again, going to the ASGE guidelines, you know, an ergonomic timeout or checklist becoming a regular part of your culture is going to help solve a lot of these problems, particularly for trainees who may be reticent to change the monitor height and the bed height after they're attending, you know, hands in the scope or vice versa, right? So here is the checklist. Most of these things we've discussed. I won't belabor them. A couple of things I didn't talk about, you know, is putting the pedals in front of you and then making sure your cords and wires are not trip hazards on the floor. So the rest of your team, oh, by the way, is also at risk for ergonomic injuries. So what can we do to help them? Well, the first is to provide assistive devices. This is Seth Gross, and his group presented this a couple of years ago now, I think, looking at basically an abdominal binder and what the impact of that was on things like having to rotate the patient or having to give the patient lifts, which we know are the two top ways that during a colonoscopy your team may get injured. These things decrease that by roughly 75% for each of those measures. And so, again, less force that your team is going to have to use. Training them, again, is going to be beneficial on how to do lifts properly. Limiting lift time, right, I think that, you know, it's sort of like chest compressions during a code. There's only so long that somebody's going to be able to do a meaningful lift. So if you're having them hold this for five minutes, you know, you're probably four minutes too long. Just have them stop and then maybe try something different. And then, again, the number one way that folks get injured in your unit is actually tripping over things or slipping on spills or those kinds of things. So taking care of those go a long way to preventing injuries. Training, I think a word on that. It's important where you stand. So I think when I started doing this, a lot of times I'm standing on the other side of the trainee where I can watch the monitor, but I can't really watch their hands very well. So now when I do this, I end up on the other side, you know, and this is great when you're watching them do general endoscopy. You might have to move out of the way when they have to start passing instruments and things like that. But that's an important consideration is positioning. Also important that you realize that you need to think about ergonomics in your entire life, right? So when you're doing your reports later on, when you're sitting on Epic for the 10th hour, right, on your vacation, you know, making sure that you're not what Andrew Huberman would call a C-shaped human sort of hunched over the computer is going to be important, right? So it all matters. It all adds up. I cannot stress this strongly enough. If you do not have disability insurance, absolutely get disability insurance. You've seen the numbers that I presented at the top of this talk. Start young or start today if you haven't. It's important you get own occupation specific insurance. But it says that, you know, you need to be a gastroenterologist working to do this. And then, you know, provision for future increases is also important. So finally, in the last couple of seconds here, a word on disruptive technologies, you know, changing the way we scope. You can see here is Basil Herschewitz with the first endoscope. He's got a little bulb here insufflating the stomach. He's got the eyepiece, not even control knobs, which we rapidly decided, hey, control knobs would be good. It'd be nice to be able to move that tip around and look around. So that worked great. We said, gee, you know, it's not great to have my head hunched over this eyepiece, which I've only done a few times, but I can tell you I don't want to do it anymore. We decided, you know, that would be good, too, is having video scoped. But really since then, we've had almost no mechanical improvements. So this is the way that we move the tip of the scope, right? So we have a wire and we have a chain. And so people want change, right? So this is a survey that Dr. Mohan will be presenting. Eighty-five percent of folks favor a more pro-ergonomic scope design, particularly adjustable, customizable control knobs requiring less force. Of 70 percent want less torque on the right-hand side. I can tell you there's no design consensus, so they didn't make it easy on us by coming up with a one-size-fits-all solution. And while everybody wanted a pro-ergonomic solution, women, 90-plus percent, wanted this. And so, again, this is incredibly important for us. What that's going to look like, I can't tell you. You know, these top products here have been commercially available for a long time. They're kind of cool-looking, but very different and have not been generally adopted, which is why I say I think an iterative solution is going to be the solution. Maybe it'll be something like this. So this is an exoskeleton that we're doing research with in our sim lab here. This is one of my fellows, Zach Johnston, putting this thing on. It helps support his arms and his back. You know, maybe we'll change our monitors out for a VR headset or something like that. This is a technology that was developed in Ecuador. So not only can the endoscopist have up to nine monitors, but the person who's helping them could be in another room and point out polyps and do things like this. So a lot of potential in the future. Again, I don't know what it holds, but there's lots of opportunity. Where we are right now is the bottom of this pyramid. Where we need to be is the top, I think. So substituting and eliminating. And so what do I want you to remember? I think for better scopes. That's really the bottom line. But until then, optimize your room design in the ways that you can see very clearly in the ASGE guidelines. Optimize your own positioning and body mechanics. Treat yourself as an endoathlete. Consider getting some personalized advice, either from a physical therapist or from some online product as they become available. It's not just you. So prepare and empower your team. Keep them safe. And then I strongly recommend that you make your unit one where the culture is to use an ergonomics checklist and timeout. And then train the next generation to do the same. Because your country, whether that's Canada or the United States, needs you. Thanks.

ergonomics

endoscopy

operator-environment interface

musculoskeletal injuries

endoscopists

endoscopic-related injury