Welcome to ASGE Endo Hangout for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, Protecting Yourself and Your Team. My name is Michael DeLutre, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted to GILeap, ASGE's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. It is now my pleasure to introduce our GI Fellow moderator, Katie-Ann Dunleavy from Mayo Clinic. I will now hand over this presentation to her. Hello, everyone. I'm a third year GI Fellow at Mayo Clinic, and tonight we're going to talk to you about protecting yourself and your team with a focus on ergonomics and endoscopy. So why do we care about this? Well, we know that endoscopic injuries can really occur beginning in the very first year of GI fellowship. Now about a third of all GI Fellows are female, and this is important because the tools that we use are not ergonomically designed for women. Almost all GI Fellows are asking for mandatory ergonomics training, but only a third are actually receiving this training currently in their fellowship programs. We also know that poor ergonomics can lead to bad outcomes for both baby and mom during pregnancies, and there is a struggle with safeguards for staff due to a lack of institutional support. Evaluation of trainers is not always standardized across programs and governing bodies. So tonight we're going to give you some tools on how to deal with this, and some of our speakers are going to speak about the core curriculum for ergonomics and endoscopy, which was developed with the ASGE. Additionally, there's always questions about how can we integrate this into our fellowship training programs, and there's been other studies and papers looking at the three areas where it's important to introduce this idea. So pre-endoscopy, intra-endoscopy, and post-endoscopy, looking at cognitive, technical, and non-technical skills while always including personalized feedback along the way. Our first speaker for tonight is Dr. Amandeep Shergill, who's a professor of clinical medicine at the University of California in San Francisco. Then we'll be hearing from Dr. Pawa, professor of gastroenterology at Wake Forest University Baptist Medical Center in North Carolina. And then Dr. Raju, a professor of medicine at the University of Texas in Houston, Texas. And our other content expert for tonight is Douglas Fishman, a professor of pediatrics at Baylor College of Medicine in Houston, Texas. Thank you, Dr. Shergill, if you'd like to share your slides. All right, so I'm going to start us off by just reviewing some biomechanical risk factors for endoscopy-related injury. These are my relevant disclosures. And the objectives are really to help you all understand the biomechanical risk factors for repetitive strain injury that are present during the performance of endoscopy. We're going to start out with just some poll questions to get a feel and a sense of where the participants are at currently in terms of their experience with endoscopy-related injury and their knowledge of ergonomics. So if you guys don't mind either texting A. Shergill 0012223333 to join, or that's the website you guys can join. And alternatively, there's a QR code here in the corner that you guys can scan. But the first question I want to ask the group is whether or not... Is learning to use the endoscope intuitive? So how many of the fellows who are on the call currently believe learning how to use the endoscope is intuitive? I'll give just a few more seconds for folks to respond. Looks like the answer is no. All right. Has anybody experienced pain or discomfort when performing endoscopy? So in this mode, I'm not sure exactly how many responses are coming in, but so far of the responses that we've received, 100% have said yes. If you have experienced endoscopy-related pain or injury, where have you experienced that pain or injury? All right, so a lot of distal upper extremity issues related to how we're interacting with our tools. It looks like neck pain and back pain, which is likely related to how we're interacting with our work environment. And so what is your guys' understanding of ergonomics? When you think of ergonomics, what kinds of things come to mind? Posture safety, so safety is a big one and in order to have a safe workplace assuming neutral postures is important. Preventing injury is definitely a key component of ergonomics. So optimization of the work site, neutral postures, preventing injury. Good habits. Culture of safety. Excellent. So I think you guys have a good understanding of what ergonomics is. So really ergonomics is the study of how work affects people physically and cognitively. It really tries to quantify human capabilities and limitations. So understanding what workers are capable of and designing work for workers instead of forcing workers into a certain job. So it's taking how people work, their physical and cognitive capabilities and limitations and applying that to the jobs they're doing. And so it's really the science of fitting a job to the worker by taking into account anthropometrics, which is the study of human dimensions and biomechanics, which is the study of how we produce force and generate movement. So these are some concepts that I just want to review because I think that this becomes very important as we're thinking about ways to mitigate risk of injury. So biomechanics is how the body produces force and generates movement. And if you guys all remember back to your med school days, muscle force is influenced by that length tension relationship of a muscle. So those actin and myosin filaments and the overlap of the actin myosin filaments and muscle force is also influenced by sheer muscle mass. And this is where males often have an advantage over females. Anthropometrics is the study of human dimensions. And the idea is really to understand that oftentimes you have a breadth of different workers. So if you're going to design a tool, for instance, this cart that you really want to be able to design, it's even that fifth percentile female or that largest 95th percentile male could use that tool and try and have optimized postures and biomechanics when they're using that tool. So if you could change one thing about the endoscope, what would you change? Oh, here we got some some folks coming in. So dials, custom wheels and knobs, smaller size. There definitely seems to be an awareness of the fact that this tool is not made for especially smaller sized hands. Lighter to decrease loads. Excellent. So what's happening with work related muscular disorders, and you guys are probably recognizing this in your current interactions with the tools, is that the external loads, how we're holding and manipulating the scope, how we're interacting with our work environment, depending upon the way the monitor and the bed are set up and where the patient is, especially if we're having to use non neutral postures, if we're repetitively using high forces, that over time we overcome the internal loads and tissue tolerances of our muscles, tendons, ligaments and joints, and that can lead to injury. And so if we look, for instance, at the microscopic level at what's going on, you can see here a control tendon and what happens to a rat patellar tendon over low fatigue, moderate fatigue and high fatigue. And you can imagine then how this damage can be accumulated over the period of time if you're exposed to these high risk biomechanical factors. So we know with endoscopy is the biomechanical risk factors from the ergonomics literature that are currently present is that there's repetition, we're performing a lot of procedures repetitively throughout the day. We're using high forces and I'll share data from our group that really established the presence of high forces during the performance of endoscopy. We're often in awkward joint postures, not just in how we're holding and manipulating that scope, but because of the sustained static loads of holding that scope, as well as depending on how the room is set up. And so these risk factors, non-neutral posture, high force and repetition, have been established in the ergonomics literature to lead to shoulder discomfort and pain, back and elbow pain, distal upper extremity pain, as many people have already experienced, as well as lower extremity pain. And what happens in the early stages is the aching and tiredness of the affected limb occur during the work shift, but they disappear at night and during days off. So that's a reduction of work performance. But in the intermediate stages, the aching and tiredness can occur earlier in the work shift, it can persist at night, and there can be a reduced capacity for work. And in the late stages, the aching, fatigue, and weakness persist even at rest, and there may be an inability to sleep and to perform light duties associated with it. So pain is a really important signal that we need to pay attention to. So our group spent some time to really establish the presence of these biomechanical risk factors in GI endoscopy, and we were able to show sort of in a very high level and summarized fashion that the loads experienced while we're holding and manipulating the scope are high risk in the left forearm and moderate risk in the right arm. And specifically, our thumb pinch forces are high risk for carpal tunnel on that left side, moderate risk for carpal tunnel on the left side, and high risk for carpal tunnel on the right side. We interestingly found that male endoscopists appear to guide the insertion tube with predominantly dial control by the left hand using both their thumb and fingers, while female endoscopists appear to guide the insertion tube with dial control by their left thumb and by torque control of the right hand. So we saw a lot higher right hand forces in female endoscopists than in male endoscopists. And I think it tracks back to sort of the poor fit of the scope. And this was one of the first studies that really established, really established how poorly designed the scope is. So this was a study of about 50 medical students, novices to endoscopy, about half of them were male, half female. And what they found was first they had the students do a task that measured dexterity, and they found that the smallest hands were the most dexterous. They were able to complete the task sort of in the shortest amount of time. Then they had them complete a simulated procedure using a bronchoscope, which is a lot smaller in size than the endoscope. And this is this darker hatched line here. And they found no difference in basic scope manipulation on a bronch simulator using the bronchoscope. But when they had the medical students manipulate the larger endoscope, they found that the smallest hand sizes, which is the slider hatched bars here, had the most difficulty completing the endoscopy test, despite the fact, again, that these were the most dexterous. So the size really does influence our ability to manipulate these tools well, because it's very tightly interlinked. If the tool doesn't fit well, we're not going to be able to hold it very well, we're not going to be able to reach those dials, and we're going to be using more force when we're doing that. So the anthropometrics and biomechanics is sort of a key concept, the idea being that, for one, we want to be able to attain neutral postures, no matter what we're doing. So for instance, to hold and manipulate that scope in a neutral posture, we really do need a smaller size in order to fit the smaller hands. And the reason neutral posture is so important, because this is the resting position of each joint. It's the position in which there is the least tension or pressure on nerves, tendons, and muscles. And it is where we have our maximum force production. So if, again, you think back to those actin and myosin filaments, this is where we have the maximal overlap. And any decrease in the length of the muscle or extension of the length of the muscle really decreases our ability to generate force. And fatigue occurs sooner when we're working in awkward postures. So part of what you're going to be learning today is going to be, through Dr. Raju's talk on optimal room setup, how do we attain these neutral postures? And really being able to recognize what a neutral posture is versus when you might be flexed forward or extended back because the bed isn't set up properly. Or when you're twisted about at the waist because the monitor hasn't been positioned properly. It's really important to think about neutral postures of the shoulder. So really at your side and not flexed or extended or abducted, which can happen, again, if the bed is too high. A neutral posture of the elbow, which is really the sort of 90-degree mark, trying to avoid extreme flexion or extension of the elbow. And also with our wrists, and this is really hard to maintain a neutral position for throughout the procedures just because of what it takes to hold and manipulate the scope. But really thinking about what our neutral postures are and what happens when we're deviating from those neutral postures. Because importantly, we know neutral postures are our maximum force generation ability. But any time we're flexing or extending, and think about how you're holding that control section. Think about how you're holding that insertion tube. We decrease our grip strength every time we flex or extend or have radial ulnar deviation. And it's further worsened if we have a suboptimal grip span. And this is where female endoscopists are at a particular disadvantage. So already maximal female strength is generally 60% of male strength. And particularly when it comes to grip and pinch strength, age and sex are the most important predictors of strength. And females at their strongest in their 20 to 30s are unfortunately equally as strong as 70 to 80-year-old men. And so I'm sure we're going to hear from Swathi about some of the data that suggests there's an increased risk of injury in female endoscopists. But to illustrate that, we can think about how much we're working during a procedure. So in ergonomics, we talk about percent of maximum voluntary contraction. So for instance, let's take these as hypotheticals. If it takes 10 newtons to turn the dial of the endoscope. And employee number one is your average female endoscopist, and her max pinch force is 40 newtons. And employee number two is your average male endoscopist whose max pinch force is 80 newtons. When we think about percent of maximum voluntary contraction, we're going to take the force that's required to turn the dial 10 newtons and divide it by the max force of the individual to determine, multiply that by 100 to determine percent of maximum voluntary contraction. So in this scenario, who is working at a higher percent of their MVC, the average female endoscopist or the average male endoscopist? to make that larger to help people respond. Excellent. So again, not sure how many responses have come through, but the female endoscopist is working at 25% of her maximum voluntary contraction versus the male endoscopist who's working at 12.5% of their maximum voluntary contraction. So already, you know, you're at a biomechanical disadvantage and as much as possible, we want to do our best to optimize both our interaction with the scope and our interaction with the unit in order to mitigate risk of injury. And so there's something in ergonomics called the hierarchy of controls. And so this is when you're thinking about how to mitigate risk, ways to approach it. And in general and in ergonomics, it's the most effective tools to mitigate controls are going to be either elimination or substitution of the risk altogether. So this is prevention through design and really requires our endoscope and device companies to create a tool that's more user-friendly, more intuitive, that really can be manipulated by that fifth percentile female to that 95th percentile male while in neutral postures and minimal forces to really decrease risk of injury. In the absence of that, it's important to think about what engineering controls, what physical changes can you make to the workplace or tool that can help you in mitigating your risk of injury? What administrative controls? How can you change the way you work, either yourself or your employer doing something through training safety culture, implementations of timeouts, scheduled maintenance of your endoscope to decrease your risk of injury, as well as what are the things that you personally can do? So you yourself, again, at the bottom of this upside down pyramid, but oftentimes the only person advocating for yourself sometimes can be yourself. How can you optimize your technique? How can you implement micro breaks and stretches in order to minimize your risk of injury? So with that, I'm just going to conclude by saying what you're going to learn sort of in the rest of the session is really ways to optimize the fit, how you can adjust the monitor bed and patient position to neutralize your postures. And once you're in neutral posture, it's really thinking about how you can minimize your forces in an attempt to really mitigate your risk for injury. And so with that, I will stop sharing and turn over the floor. While we're waiting for some questions to come in through the Q&A or the chat, what I found was really interesting was you talk about the neutral posture. I actually think that maybe as fellows, we don't have a good understanding of what the neutral posture is, even outside of the endoscopy suite. You know, many years of studying over a desk or leaning towards a computer, I think maybe we have a skewed view of that, that it's possible we might even need to take a step back further to understand how to even obtain a neutral posture in our everyday life. I talked a little bit about that through something I learned through singing opera called the Alexander Technique, which has tried to help me just learn what a neutral posture is. But I agree 100% that it's so hard to maintain that if you don't already have a good baseline before you walk into a stressful environment. I know you also talked a lot about what is, how if we were to change the scope, what would we do? And I'm curious, is this something that might actually become a reality or do you think that this is a dream that we're having? And what type of things, like a lighter scope or a change in dial or a complete overhaul would actually make a difference to our practice, especially for the full curtail of female to male endoscopists? Yeah, I think it's actually a really exciting time in GI and really interesting and innovative things that are potentially on the horizon that hopefully we'll see during even my career. So I think that change hopefully will be coming. And I think that it's a result of sort of all of our efforts to really bring attention to this. I mean, I've been talking about ergonomics since I was a fellow, which I'm not going to tell you guys how long ago that was, but it's been a very, very long time that I've been sort of focusing on this and trying to bring attention to this. And I think finally in GI, we're at a place where ergonomics is sort of part of our, you know, it's part of our culture, hopefully within fellowships, it's part of your guys' training. But I would definitely echo the sentiment that it's interesting how many people don't think they know neutral postures, but really if you just like close your eyes and think about what feels comfortable and you open your eyes and look in the mirror, that's going to give you a sense of what your neutral posture is and trying to replicate that as much as possible in the endoscopy suite is going to be important. And with tools, I, you know, people, I've definitely seen endoscopy companies claim that they have more ergonomic tools on the market. Maybe they're lighter with the advent of disposable endoscopes, or maybe the opportunity to have more customizable tools available, but there really is the potential in this space for even the prevention through design. And I hope that that's what's coming to GI shortly. That's great. Yeah. And I'd point out kind of to Katie's point that in our everyday life and even within endoscopy, right, I think the focus is often on basic endoscopy, but when you start doing advanced procedures, ERCP and enteroscopy, like it almost sometimes goes out the window and it's, and so I think we'll hear a little bit about maybe some maneuvers and I'm, again, it's one of those things that I don't, I think we really do focus on colonoscopy because it's what the majority of people are actually doing. But I think it's certainly there, but yeah, in our everyday life, you know, I have a 200 by 500 millimeter lens camera and I'm like carrying it. I have a sling for it, but like it's, it's awkward and you get what's called warbler neck when you're looking up, taking pictures of nature and, and it's like, wait, it's totally a, we kind of throw out everything we're trying to do right here. And, and we, in our personal life, Katie, do you want to tell us a little bit about the Alexandria technique that you talk about and what it is? Sure. So it's a very old technique. FM Alexander is actually born in 1890s or so. And so he was originally an Australian actor and he kept losing his voice over and over. And so he decided he needed to do something about it. The doctors couldn't help him. And so he really started staring at himself in the mirror, kind of what you described and trying to see where the tension was coming from. And I think he learned a lot about the biomechanics of how his body worked and the bad habits he had developed. I think he was in his forties around this point. And through this, he kind of has this concept of inhibition or doing less. And so overall the Alexander technique is a technique that developed from this to teach people how to live their life in a more neutral posture. And a lot of it comes from education, just as Dr. Shergill was talking about. So even the aspect of just taking breaks to relax your body or look in the mirror and watch yourself. And a lot of it is through visual imagery guided speech. And so it's not like going for a massage or going for physical therapy where someone's helping you manipulate your body, but you're actually guiding your body into the correct position. But it feels really strange at first, especially if you've been used to being like this or like this, or your neck is like a chicken, which mine was when I started out. And so it's something that I think sounds a little strange in the beginning, but it's actually used worldwide by actors, opera singers, dancers, just to maintain kind of durability and longevity of your instrument. And so in many ways, our instruments are our hands, our whole bodies, really. And so it's just another thing to think about, but I think it echoes the same sentiment, whether you do it through yoga, meditation, or just mindfulness in the endoscopy unit. Excellent. Well, I don't know if we have any more questions coming through or anyone else in the panel has any questions for Dr. Shergill, but thank you so much for your time this evening. Next up, we will have Dr. Pawa, who will start to share her slides here, giving us a little bit more overview of the core curriculum that was developed in this realm. All right. All right. Good evening, everyone. I think I'm going to piggyback on Amandeep's talk, which was an excellent overview of the problems that we potentially can face while doing endoscopy and probably take a step back and talk about the history of the injuries, so to speak. So the scope of the problem that we are facing here, I'm trying to get this off the screen. So the goal here is to understand the prevalence of endoscopy-related injury in training and in practice. And then I'll briefly touch on the ASGE guideline, which I was a part of, and which spoke about the role of ergonomics for prevention of endoscopy-related injury. So as we know that there is now a demand for increased GI endoscopy, and with the reduced age for colorectal cancer screening to 45 years, we are going to see increased colonoscopy utilization both as a screening tool and for post-polypectomy surveillance. We are also using AI now in increasing fashion, and there'll be an increase in our adenoma detection rates, which we've seen already, which will lead to more procedures. And we're also utilizing advanced GI procedures more and more for conditions that would traditionally require surgery. Also, our users are changing, and 51% of our active GIs are now greater than 55 years of age, and also we're seeing increasing women in GI, more than we've ever seen before. So when you look back, musculoskeletal injuries have been common in endoscopists. And this is a very busy slide, but I put it out there just to show you the gamut of what has been done. The first paper that came out was in 1994 by Pushback. It was an ASGE survey. Most of the, almost 99% or maybe even total of the 265 participants were males, and 57% had reported injury. Fast forward to 2020-21, and you recently saw increased work in this arena with the largest study to date is the ACG paper, which was, it was funded by the ACG, was about 1,700 members who participated in this survey, and showed that 75% of them complained of injury. Now, there is a robust body of literature, but it's also primarily survey-based because that's the only way we've been able to capture it, and this includes both international and studies and surveys based out of the U.S., so it has ranged anywhere from 39% to 89%. And so there are two things to think about. One is endoscopy contributes to injury, and this was amplified in a paper that came out of Mayo by Hansel in 2009. It was a case-control survey study, and showed that GI physicians, when compared to non-procedural internal medicine specialties, had increased rate of musculoskeletal injury. And then came certain key papers, starting with the 2015 ASGE paper, which was, which involved 684 practicing endoscopists, 53% of which experienced DRI, or endoscopic-related injury, or endoscopy-related injury, and the risk factors which were kind of elucidated at the time were if they performed more than 20 cases per week, if the endoscopist did more than 16 hours of procedures per week, and the number of years they performed endoscopy. And these were the risk factors which were independently associated with injury. And again, in this particular study, 55% of the endoscopists required interventions, be it taking a break, or NSAIDs, or physical therapy, or surgery. In 2017, the AGA came out with their survey, and this survey, unfortunately, is in abstract form only. It was 826 practicing endoscopists. They showed that women and men equally were prone to injury, but women had more injury of the wrist, elbow, shoulder, upper back, right thumb, and I want you to keep in mind Amandeep's presentation, where she's done seminal work in this field, and has shown where more forces are generated based on the inadequate endoscope that we have, or the design of the endoscope. Risk factors in this paper were procedure volume, age, and prior injury, and training in ergonomics was rare, about 4.5%. In 2021, the ACG came out with their paper. This was the largest study that I was talking about, about 1,700 practicing endoscopists, 75% of which experienced endoscopic-related injury, 90% said they had more than one injury, 20% took time off for injury, 12% required surgery. And risk factors, again, years performing endoscopy, the more years, the more chances, hours per week performing endoscopy, and 61.5% of these participants reported no training in ergonomics. And this is just abstract, a more graphical representation of this particular paper by the ACG study, which reported…which had about 1,700 non-trainee practicing gastroenterologists, 74.5% were…I'm sorry, 583 females, the rest were males. And again, both males and females reported about 75% of them reported injury. And in this particular paper, we started to see a difference in the way men and women experienced injury. So, the women complained more about wrist, hand, finger, thumb pain, more upper extremity, upper back pain. Men complained more about lower back pain and elbow. Also, the reported mechanisms of ERI were different. With women, it was more non-adjustable bed, monitor, more twerking with the right hand, as opposed to the men, which then also complained more about use of elevator or lead apron. So, all these studies are painting a picture here that endoscopic-related injuries are common, and the more you scope, the more the chances are that you will get injured. And this is…I did not want to leave this behind, but these are the studies that are exclusively done on the fellows, starting from 2019, when the first paper came out, to 2022, which was the ACG survey. And again, paints a little bit of a dismal picture that all fellows were…half of the fellows, at least in our paper, were already reporting ERI in their first, second, third year of training. So, the societies took heed, and I don't mention this, but I know Katie showed that the training committee did publish a curriculum for the fellows on endoscopic-related injury. But what I was more involved in was the society guidelines that came out last year. And this is…what we ended up doing with this was…I think Doug was part of it, and Rich Kwon from University of Michigan was also the lead author on these guidelines. We also had a whole group in the standard of practice committee, which were involved with these guidelines. Amandeep was our expert…content expert on those guidelines as well. So, it was a group effort, and we thought that the time was right. And even though we knew that there wasn't the most robust data, because these weren't randomized controlled trials, we knew that something had to be done, that ERI was real, and we would do our best to see what we could come up with. So, we ended up doing a very thorough systematic review and meta-analysis of whatever had been published almost starting from the beginning, and we took 17 survey studies, about 5,000 respondents, and we found that the overall rate of ERI was about 58 percent. The most common sites of ERI were hands and fingers, back, and neck. We then took eight survey studies that had males and females, or a higher group of males and females, and these were about 3300 respondents, and we found that ERI in female endoscopists was more than male endoscopists, and it reached statistical significance. So, female endoscopists had higher odds of developing ERI when compared to their male counterparts. So, I'm going to skip the next few slides, because I think they were described in Amandeep's slide set, and also, I want to leave more time for questions and interactions on this, so we're not going to talk too much about work-related musculoskeletal disorders. This is my fellow, who you can see is having a tough time with the scope, and again, the same awkward posture, the long hours of standing, sustained static load, repetitive motions, all predisposing us to endoscopic-related injury. And again, this is Amandeep's slide, which talks about the pain in various areas due to biomechanics and non-neutral postures. And again, does hand size matter? And I want to kind of rush through this as well, because initially, you know, the first few studies that came out, starting with Cohen, it was more about perception of effective hand size, and that fellows felt that hand size affected endoscopic learning. Our study did not show any difference, though we saw that the majority of women reported that they were wearing smaller-sized gloves. A study by Miller in 2022, I think this came out of Mayo, measured procedural and anthropometric factors and found that small-handed endoscopists had longer colonoscope insertion times, and so we're building a story here to the study that Amandeep spoke about, where it was felt that smaller glove size, or those with smaller glove sizes, were slower with a large-handled endoscope and reported more fatigue. So, these were some of the guidelines or recommendations that came out of the ASGE more recently in the last year. And again, our committee acknowledged that the study of ergonomics was new, there were scant studies, but we did our best to produce these evidence-based guidelines. And again, the guidelines were done in a great manner. Where it says recommend, that's a strong recommendation. Where it says suggest, that's a conditional recommendation. And so, I'm just going to go over the guidelines really quickly. I just want to stop here and ask Doug if we have time, because I want to give Dr. Raju the time as well. Do we have a few minutes, or I can skip and go straight to Dr. Raju, Doug? Yeah, I think if you want to just go quickly on the recommendation. Okay, so this is a summary of recommendations that we all came up with. So, the first recommendation was that the ASGE recommended ergonomics education to reduce the risk of ERI. We still don't know what education will be best, but it's important to know what's available to you. So, you all are aware of the ASGE training curriculum, which was led by Dr. Catherine Walsh. There is an excellent resource, which is the ASGE video, Ergonomics Essentials for Your Practice. This was Dr. Shergo's video, which is available on the website, LEAP website. There are video GIE series. This is by Drs. Chang and Dr. Patrick Young. There are YouTube videos, phenomenal as well, on endoscopic ergonomics by Dr. Raju. So, know that there is stuff there for you to look at and to start learning from as well. So, that was the first guideline. I want to briefly talk to you about microbreaks, which will then lead us to our second guideline, or our second recommendation, sorry. So, microbreaks, you can divide it into three categories. The first is short, biologically meaningful breaks, lasting 30 seconds to two minutes, meaning you just take a break and do nothing. In fact, even if you sit or if you just kind of break away from what you're doing, that's one microbreak that you have. And then there's another one, which is targeted stretching microbreaks. And there's a robust surgical literature on this, which talks about how that has helped the surgeons. And it's about, again, they have defined it as about 1.5 minute stretching breaks every 20 to 40 minute intervals. And they're specifically targeting the neck, the shoulders, back, wrists, hand, knees, and ankles, as you can see some of these pictures here. And then there are obviously macrobreaks, which are built into your schedule, which again, require more administrative control, not in your hands that much, where you have a half hour lunch break, or you have, you take a hard break, a hard stop at your, during your midday, so to speak. We call those anesthesiologists where I work. Yeah, yeah. And so, interestingly, our study with the, with the ACG showed the lower likelihood of ERI in those who took breaks. Didn't matter what you took. Didn't matter if you took a micro break, or if you took a targeted stretching break, or you took a macro break. Just so long as you took a break, you had lower likelihood of endoscopic related injury. And again, this is a surgical literature, from the surgical literature, another study, which talks about targeted stretching micro breaks, which also showed that the surgeons perceived improvements in physical performance, mental focus, and wanted to incorporate this in their practice. And as you know, depending on how we do, if you're doing EGD and colons the whole day, maybe between procedures is a better way to do it, because our procedures are not that long. But some of us are interventionalists, and then some of us do third space endoscopy, and these procedures get longer and longer, even two hours, three hours. And then in those cases, doing them in, while you're during the procedure, that might be the better way to do it. So the ASGE suggests, because there was only so much data, that GI endoscopists take micro breaks and schedule macro breaks to reduce the risk of ERI. So then we talk about neutral body position, which I think we've talked about quite a bit. So basically you're talking about a position where you are standing comfortably on both feet, you've got equal weight distribution, you've got your natural curves of the back and the neck, and it's basically the position where your joints are naturally aligned. So you're working with your joints at about the midpoint of your range of motion, like seen in those photographs that Amandeep shared. And so the next few guidelines are based on neutral position of the monitor. And I think by that we meant that you can either, you should be looking at the monitor directly in front of you, or just maybe slightly below eye level. And so your monitors should be on booms, or if they're based on the wall, then they should be able to move so that you can actually adjust their position. So that's key. And many endoscopy units, unfortunately right now, are struggling with not having these kinds of adjustable monitors. So this was a recommendation that came out of the ASGE, that neutral monitor position during endoscopies to reduce the risk of ERI. And again, most of this data is from social literature, where it was shown that neck strain was lowest when you actually were positioned that way, the monitor was right in front of you. And again, extrapolated from the surgical literature, where Amandeep's seminal work again, published in GIE 2009, which said that your viewing angle should be so many degrees below the horizon from the eyes with a viewing distance of 52 to 182 centimeters. The same thing came up with the neutral bed height. So we should have adjustable beds, and the ASGE recommends again, the use of a neutral bed height to reduce the risk of ERI, meaning your bed should be at an optimal, you should be able to adjust your table height so that you have about, so that it can be 10 centimeter below the elbow height. So between elbow height and 10 centimeter below the elbow height, which was associated with significant improvement in the rating of discomfort. And lastly, the ASGE suggests the use of anti-fatigue mats to reduce the risk of ERI, and prolonged standing, especially if you're doing long procedure, it's been a long day, has been implicated in lower extremity tiredness, discomfort, swelling, low back pain. And so the use of floor mats, and again, coming out of surgical literature. So not much of the GI literature thus far, but coming from the surgical literature, these were studies out of urology, I think, or our surgeons in urology, and they talked about floor mats associated with less pain in the feet, knees, and back, and also overall discomfort. So with this, I think I'm going to hand over to Dr. Raju. All right, I want to thank Doug and ASGE for this kind invitation. And I want to congratulate both Amandeep and Swati, they've done a phenomenal job. Amandeep for doing some high quality original work when most of us did not think about it. And Swati and her colleagues for coming up with a guideline. I think it's very important. So I've been doing endoscopy since my first scope was done in 1986. So I've been doing it for quite some time. And injuries, as you can see from the work presented by Swati, is a real problem. As endoscopists, we move away from being internists, right? We try to use more of our hands to do our work, and slowly forget our cognitive aspects of gastroenterology. And when you get injured, and the injury leads to a deficit that cannot be repaired, you're basically done. By the time you've already forgotten your cognitive aspects of gastroenterology. So I just want to make that statement because this is very important as endoscopists to keep ourselves safe. What I'm going to do is most of the material, both Swati and Amandeep have covered very well, but this is such an important topic, it's worth repeating. And as they were giving the talks, I reduced my talk by about 50% so that I don't repeat, but I wanted to showcase certain things that are very important. So there are three important things to keep yourself safe. And those are basically planning your schedule, figuring out how to use your scope, and make sure that scope is a proper scope. I'm going to comment on that. And then managing yourself in between the monitor and your processor, because you're standing in between the processor and the monitor with the patient in front of you. So these three things are very important. So when it comes to schedule, when you start immediately after your fellowship, you are eager to do scoping. And if you have a schedule where you'll be scoping every day, five days a week, this is going to certainly put you at risk because you'll have injuries as you do the scopes again and again, every day. And as you know, there is a vicious cycle of injury leading to inflammation. And then next day, you come back and have another injury, more inflammation, and eventually you'll have musculoskeletal injuries and degenerative joint disease. So you don't want to get into this vicious cycle. And how do you prevent that? So Swati has commented on this. Amandeep has talked about it. Important to set your schedule so that you have time to recover in between long days of procedures. Say, for example, you scope on Monday, make sure you take Tuesday off. Do something else, do a clinic, do something else, but don't schedule yourself long days of endoscopy. Typically, our endoscopies are set in such a way that you have a room and you keep doing the scopes all day. So important to take a break in between days full of procedures. I also feel very strongly, although most of us take pride in not taking a lunch break when the whole team takes a lunch break, give yourself a break. Make sure, even if you don't like to eat lunch, take that half an hour or 45 minutes between your morning and evening sessions. And I do this. Many of my colleagues don't want to do this, but I make it a point that I ask for a lunch break and I take my lunch break because that will do two things. One, if you're already doing four to six hours of procedures in the morning, you'll have a lunch break. It will get you time to recover. Your afternoon patients will get a better service from you. And by that time, you are also recovered from the strain of doing cases in the morning. So important to keep this thing in mind. I want to repeat again, I think Swati made this point of taking micro breaks. That's good to do that. And probably not a bad idea to have an elastic rubber band with you on your table and do the stretchings of your chest and different parts of your body. That is going to be very helpful. So the concept is you want to break the vicious cycle by taking breaks in between days and also a break in the middle of the day. One thing fascinating about the Japanese endoscopists, they work very hard, but they all take a lunch break. Everybody goes for a lunch break. So the next one is a scope. Don't use whatever scope that is given to you. Make sure you check the dials. Imagine that you are doing a colonoscopy where you know that the procedure is going to be a long and complicated procedure. And the assistant brings a scope, doesn't check the dials. The scope has gone for repair, came back, and the dials are too stiff. If you have a scope with stiff dials and you start doing the procedure because you don't want to waste your time. You know that the dials are stiff. You don't want to waste the time. You want to keep moving. I can tell you that you're going to destroy your thumb by the end of the procedure. So make sure either you get into the habit of checking the dials and have some play or tell your assistant, hey, make sure you check the dials before you bring the patient, bring the scope to the room. So very important to keep that thing in mind. This problem happens when scopes go out for repair and the repair personnel have tightened the dials too much. So something to keep in mind. So that's what I was talking about the dials. The other thing is, Swati mentioned about injuries of the small joints of the hands, especially in women gastroenterologists and trainees. So when you're doing a procedure and you feel that, hey, I'm using too much of right, left turning and I may need to keep it like this. Think about the locking device. You have a locking device for up, down. You have a locking device for the right, left. Lock it and then give yourself a break. We forget about those small things that are inbuilt in the scope. So something to keep in mind. So the other thing is when it comes to self, so you're in between the processor and the patient and there are several things that we need to do to keep ourselves safe. So these are all the things that my colleagues have already talked about, but I'm going to take you through using these illustrations so that they stick in your mind. So coming to the patient, let's talk about a patient. So this is the bed that is actually too low. When the bed is too low, you are going to actually put too much strain on your back because you need to lean forwards. So that you could avoid by making sure you get your bed up. So don't start the procedure until the bed is at the appropriate height for you. Appropriate height, how do you find out? I feel that you should figure out whether your elbow is about 90 degrees or maybe 10 degrees below that. That's the height you want to bring the bed up. The next thing is, so to just make the point again, here the bed is low and you want to bring the bed up and this actually gets you into a better posture. The other one is monitor. If this monitor is fixed and you're working in that endoscopy unit, I can tell you that you're going to develop problem with your neck. It's better to have a monitor that is mobile or adjustable so that you can bring it down that is convenient for you. Say for example, you go to a practice where there are all men who are all tall and they have monitors fixed at a particular height and if your height is not of the same height as the men, you may get into trouble with your neck. So when you're going out into looking for practices, check out all these things because there's no point in getting injured while trying to take care of patients. Dr. Raju, there's a question from the audience and I'll kind of tie in with one of those. It relates to your last question, but how do you recommend a fellow sends back a scope if it seems different or not ideal? I think the context is sometimes as a trainee, you probably are a little bit resistant. And in the same way, I'm always asked the question when we talk about this stuff is, as a faculty, you're doing the scope, as you, I think, said very nicely, it's whoever's doing the scope. But obviously, the faculty then is potentially at a disadvantage, but the goal is that the trainee and the table should be at the fellow's height. Obviously, if you need to make a change, that's obviously a subtle discussion point. But again, that first question was, again, I think a lot of it gets at the, perhaps if I'm interpreting it right, is the comfort level of a fellow of saying, hey, this isn't right. In my practice, I let the fellow adjust the table. If I'm working with somebody who needs the table to be lower, I want the fellow to do that so that he learns the habits right. And if I have to take the scope back, I get the table up. And I think we just have to kind of let the fellows know that's okay. And I think sometimes that's the, maybe to the other point. And I think that's where it becomes. Doug, if I may add, I think there's also some pushback. I have felt pushback from, it has to be a team effort. Your techs and your nurses have to buy into this way of thinking, because there's a lot of pushback when you say, oh, this is tight. These dials are not the best. You need to take it back and get me another one. And you can almost see that no one's appreciating that. Now that's happening at a level of an attending. You can almost imagine what's gonna happen to the level of a fellow. So there's also this worry about a real worry, in fact, sometimes with this kind of issue. Yeah, I think you make a good point, Swati. But that is one of the responsibilities of the director of endoscopy, to safeguard everybody that is working there. We give too much of importance to everybody, but not to our own physician colleagues. So, if the dial is too tight, I tell them to send it back to repair. Imagine people getting injured, right? If somebody has done it to it, I can make anyone double up thumb injury by giving them all their scopes with stiff dials and let them do one day scoping colonoscopies. One day scoping colonoscopies. They will have problems because this is not a very strong joint. Yeah. So again, I think as what Swati talked about, I just want to make a point here again, that is about making sure you have the monitor at the correct height. And the way to figure out whether the monitor is correct height is when you look straight, you should be able to see the middle of the screen. So, that's the correct height for you as an endoscopist. So, very important. These are all small things, but they make a big difference. So, the other one is, say for example, you're doing an EGD in the left lateral position or a colonoscopy in the same position, but if you have to make the patient go supine for whatever reason, then automatically that patient turning almost 90 degrees to the other side or 45 degrees to the other side, what will happen is you will automatically have to change the direction of your head and look crooked to see the monitor. If you have a monitor that is adjustable, very important to move it so that you are in a neutral position. So, this I actually, I do a lot of colonoscopies, that's my practice. So, when I put a patient from left lateral to supine, then I automatically move my monitor that is in front of me towards the head end of the patient so that I don't have to turn and turn my head to the right to see the monitor. I want it to be adjusted in such a way that I can be in a neutral position. So, you can see the same concept. I'm just repeating it because these are all important concepts. You have the monitor move and you have a crooked head there. And then if you move the monitor, it becomes very comfortable. All right. So, now let us look at the processor and how the umbilical cord comes out. It's not uncommon for your assistant to actually give you the scope with a little bit of a coil on the umbilical cord. If you don't untie this or take the loop off, this coil can put a lot of strain on your left side of the body by pulling you down. So, important to make sure that you straighten and you can straighten at the beginning of the procedure, but if in case you've actually formed a loop and you brought the loop out, you can actually ask the assistant to disconnect and take the loop off so that you have always a straight umbilical cord to the processor. That is really very important to save yourself the stress. So, now let us talk about the endoscopist. They've talked about your posture, proper shoes, and a mat, a cushion mat that takes some of the stress out of you. So, here you can see the... I do the scopes standing straight in a neutral position, but I've realized that if my nurse puts the patient in the middle of the bed, automatically that makes me go in a stooped posture. And that you could avoid at the beginning by having the patient come to the edge of the bed that allows you to stand in a neutral posture and that takes away strain on your back. So, having a neutral posture, what we are talking about is ears above the shoulders, back straight, and hips in line with the spine. So the other thing is, how do you stand? You want to make sure that you have a relatively easy posture on your lower limbs, not locked. Instead, a little bit of flexion at the hips and also at the knees. This takes away a lot of strain that can happen on the joints. All right, so that is something to keep in mind. In a locked posture, slightly bent knees and the feet at shoulder width apart, that gives you the best posture for doing procedures comfortably. In terms of the bed height we talked about, right, you want to have the bed height at a point so that when you're this angle is less than 10 degrees. If it is more than that or less than that, you'll put a lot of strain on your elbows. If you stand away from the patient, you have the best opportunity to stay out of trouble. But when you're standing close to the patient, you have to hold the scope very close to the gluteal region, and this becomes very stiff. And when it becomes stiff, you have to use a lot of force with the grip. That is probably going to put strain on your on your grip and the wrist. Instead, if you step back, you can actually hold the scope almost like a pencil grip. And that also allows you to actually use your core to move in different directions. So if you have a scope straight out with the seat, one of the things Doug was talking about the seat on the bed, but I have my seat outside, and then you can move your torso right, left, and maybe take a step to the right, step to the left, and use your core to actually transmit the movements from here straight. As long as you actually give a little bit of support at the seat for that rotation to be transmitted to the tip of the scope. So we talked about it again. I just wanted to give you a repetition of this. You try and do it when you're going for your endoscopy tomorrow for doing a colonoscopy. If you hold your hand very close to the anal canal, the scope becomes pretty stiff, and you have to have a lot of grip power to move even a few degrees. But on the other hand, if you stand back, this will make it a little bit a lot easier. And also try to use, in order to prevent injuries, if you use your torso, bigger joints, and bigger muscle groups, you have less risk for causing injury to yourself. So the concept I'm trying to just highlight again by holding it very close versus with the pencil grip. People have shown that the stress on your hand is less when you're coming back during withdrawal. If you can actually use a towel or a gauze, then the amount of pressure you have to use will be less. If you think about it in older people with arthritis, what do they have? They don't have a spoon. They have these spoons with big handles so that they can manipulate much easier with a bigger handle. So we talked about schedule. Give yourself breaks in between days of procedures, during a day of procedures. Think about the scope dials that are not too stiff. And then managing yourself as you're doing the procedures, adjusting the bed, adjusting the umbilical cord, patient's position, monitor position, etc. You know, most of us probably go to the gym and one of the things we learn is, hey, try to learn how your body is responding to whatever exercise you're doing and try not to overdo yourself, right? That concept is, you know, if you go to any personal trainer, that's what a personal trainer tells you. So you have to keep that thing in mind when you're doing endoscopy to constantly hear your body and make adjustments. A particular movement of the scope can be done either moving your fingers, moving your wrist, moving your elbows, moving your shoulder or moving your torso. And try to achieve those movements by doing different parts, using different parts of the body so that you can give rest to a particular part of the body when you have used it too much and still accomplish your work and not get into the habit of using the same part of the body and get into overuse injuries. Thank you. That was really excellent. Thank you so much, Dr. Pawa, just giving us an overview of these really essential guidelines. I feel like they're going to be the first step in a lot of good research in this area but also in a lot of next steps, not only for fellowship but for continuing medical education for current endoscopists. And thank you, Dr. Raju. I really loved the three S's. I feel like I need to take some of those practices back to my own day as a fellow. But I'm curious to hear what all the faculty think about how do you model some of these behaviors? Obviously, you are excellent at modeling ergonomics within your own endoscopy unit but sometimes people are not as open to these approaches. And I remember as a first-year fellow, I didn't feel like I had the right to ask for certain things. I barely knew where the bathroom was. I didn't want to ask for a dial extender or move the monitor. And I think that now it's starting to become part of the training is that you need to empower yourself to set yourself up from the very first moment you step in the room. But it does take time to get there and I am worried that first-year fellows will still experience a lot of pain and stress while they're trying to find their voice. And so I'm curious how you guys have done this at your own institutions. I guess I'll speak here. It's interesting, like I said, I got there were some really, for the fellows here, if you don't realize that the faculty we brought today are really the experts in the field and they've been doing it for a while which is pretty awesome. And it's slowly growing and it really is kind of this long fledgling field but really starting to get pockets in different areas. And so I think that's the one thing is kind of finding an ally in your program. And I think, and I can hear it and I know from others, you know, we have a voice on the national level and in our societies but you go back home and there's 10 doctors that think you're crazy. And so I think some of that is trying to do it in a constructive way and it starts with, I think, enabling the team, that's the techs, the nurses, that you care about the patient safety, obviously, but your team safety as a priority. And, you know, we don't, we kind of do it now, we don't even talk about a classic and this ergonomic timeout but I think it is, you make sure that and you have to audibilize some of these things, hey, what we're doing and why we're doing it. And certainly I'm more vocal about it probably than some of my peers but it is, hey, you know, and you can make it fun when we first started doing it, hey, let's do some stretching exercises, everybody, you know, I would like, not make people do it but, you know, we would at least try to make it fun. And so I think there's ways of kind of incorporating these things and it is small steps, right, as first-year fellow you may not feel comfortable but hopefully as a program, and I'm a fellowship program director, it's like we need to be able to on day one to say, hey, we're all part of the same team and we want you to be healthy and happy, we want your patient to be happy, and I think those are really critical pieces and it's hard. And so I think people like just have to kind of, it has to be part of the culture, I think that was on Amandeep and one of the first comments that someone made about what ergonomics is, it is, it's a culture of safety, it's a culture of health and I think that, like I said, we don't all strum our violins like a Stradivarius, but I think that's how I envision the colonoscopy being is, you can't see me, but so I think that, to me, that's the biggest piece is getting some buy-in, you don't, everybody doesn't have to buy in, but when I came from Boston to Houston, people were, you know, doing all kinds of stuff like putting the scope over the bed and, again, our patients are smaller, so that was, but people thought I was crazy for trying to get rid of that, and then the next year another colleague came from Boston, so we kind of infiltrated a little bit, but it was able to, you know, say, hey, this is a better ergonomic way of doing this, and again, sometimes you can't just be alone on the island doing it, so, but I have been, and I'm sure Raju at MD Anderson probably experiences the same. So I want to share something very important for the fellows. Right now you are at the beginning phase of your gastroenterology career. Before you see an orthopedic guy, get your insurance, not medical insurance, disability insurance. That is really critical, and I've seen people who have actually been therapeutic endoscopists who have to stop practicing in their 40s, and say, for example, you have forgotten your enteral medicine, you've forgotten your gastroenterology, and you don't know how to manage hepatitis B, hepatitis C, you don't know how to manage IBD. What are you going to do? So important to get insurance. That is really critical. I think the most important message, even if you don't follow what we talked, get your insurance. The second one is, there are two aspects. Right now you're in training, but when you go out into practice, set your goals for the long haul, for the next 30 years of practice, and how you plan your schedule for the week will decide whether you can run for the long haul. Even marathon runners are not going to run everyday marathon, right? They're going to take their breaks, so make sure that you have breaks that is critical. And it doesn't mean just because somebody else is doing 15-20 procedures that you have to do 15-20 procedures. You know, unless you set the limits for yourself, you will probably get injured very quickly. I actually think that's a really good point. You know, many of us in our third year, we're starting to look for jobs, and I do think that the most leverage you're going to have is in that early interview process. But when we tour endoscopy units at places we go to visit, I think we should be keeping a really close eye on A, the culture, but also B, how are these rooms set up? You know, is it a construction project that may happen in the next 10 years, or are they already designed for you to be kind of optimally used? And it's not something I really would have thought of because I'm not an advanced endoscopist. I'm going to go into IBD, but I still will do colonoscopies and endoscopies. And I think the point is very well taken that there are a lot of questions that we should be including in our package so that we can have a durable and a long career that's safe. I just want to make one point. I've seen a lot of fellows, all that in the third year, when they're looking for jobs, they're just comparing notes about how much can they make. They may be in the lousiest endoscopy unit that can put them out of commission. So a lot of things that are important to enjoy life and not have issues like work-life balance or burnout could be as simple as having a monitor on a boom that makes it easy and you have a great team. All those things are more important than another $50,000 or even $100,000. I put in the notes, and again, the comment about there's physician-specific insurance. So you actually don't have to go, like as a pediatrician, look in kids' ears or as an internist, take care of diabetes. So you actually, even if you can do endoscopy, you can do GI-specific care. But it's best if you are a second year. You can't wait till your last year, but there's some scalability such that for most of these policies, you have to wait five years before you can scale your salary. And so if you do it as a second year, you have a shorter time frame in which to do that. So feel free to reach out to me. I've got some, I have a good guy, as they say, but I get nothing from it. But I certainly have gained some experience over this over the years. Fortunately, I've not had to use it. I paid a lot for it, but I do think there's a lot of value in it and certainly can give advice on that, I think. So anyway, I think that's a good point. I wanted to comment. There was a question in the chat about the C-loop, and I put a video. I really encourage people to use it because it has changed my ergonomic strategy in both what I teach and what I actually practice. And I think it gets to one of Katie's questions, I think, earlier. But I hold the C-loop on the bed. And again, my patients are a little bit smaller. But then I really am torquing using my forearms and my torso rather than using a lot of rotation. Now, certainly in a difficult colonoscopy, I may still do that and resort to my old ways. But again, I encourage you to check that out. And happy to answer questions about that once you've looked at it, if I can try to help brainwash anyone else. So what Doug mentioned about an ergonomic checklist, they have in front of you so that when you start a procedure, and you can best start when you're a fellow because you haven't learned so much that you have to unlearn. And then kind of when you're there, they're just making sure your monitor is in the right position, which basically means you are in a neutral posture. And that's where those dimensions come from. Meaning looking like Dr. Raju said, so your beds at elbow height or below, your pedals are near you, your cords and wires are away. That's more of a safety hassle, but you should know that. Your lead aprons, which we didn't talk about, are two rather than one. You're wearing two-piece lead aprons, which kind of divide the load so much. And then again, your dials, once you get in the habit of doing that as a timeout, that actually might then, you might then just, this might go a long way as you go into your practice, I think. Katie, do you want to take us home? Sure. Well, thank you everyone for a really fantastic evening. I just have one last question before we close the evening, but do you think that we should be starting to include ergonomic techniques as continuing medical education? I know that fellows are interested and younger faculty or faculty who scope a lot are interested, but I do think that there's still a fair amount of people who maybe don't have the information and maybe are not going out and looking for it. And that if it was included in CME, it might be a way to just disperse that more readily. Maybe you have more information for me. So I want to make a comment. Anyone who teaches endoscopy as a mentor has an obligation to his mentees to watch them and correct. It's not about going to the CECM and coming back. You know, everybody will get there and will come back. It's to teach them proper techniques and give them feedback. That we should make it as a point. And I try to, when somebody is coping, I actually stand back and I watch them. And I tell them that, hey, you're a little bit off here. You didn't take off the umbilical cord loop. Your monitor is not right height. Because the fellow is always eager, right? The moment you give the scope, they don't want to do anything. They just want to do this. So important to give that feedback. I think it's important for every teacher to do that. And if you don't have that, you have to figure out, like Swati was saying, make a checklist. And we are smart enough to figure out and reflect on what we are doing. And then make corrections. Yeah. Swati and I had the experience that I think people don't quite get it yet. That ergonomics is what quality was 15, 20 years ago. And, you know, it is kind of getting this critical mass where we can kind of, we're going to have to give it and see me like broccoli. When you're a kid, you just kind of got to eat it and figure out ways to sneak it in the food. And again, you get experts and people that are really enthusiastic about it that maybe get a fellow excited about doing some research. And I think that's where the best yield, I think, is going to be. But I do think it's kind of still requires a little bit of push from and from centers where there's experts that can kind of preach. And sometimes it's because of an injury or it's because they've seen someone else be injured. So I think those are all good things. I completely agree. And I'll also say as a fellow, you can be your own advocate. If your consultant or attending is not commenting on how you're doing, you can say, this is what I want to focus on today. Can you watch me and give me feedback? You can ask for hands-on feedback if you feel like there's pain in certain areas. It could feel weird to do it at first, but let me tell you, it's very rare that someone's going to say that they're not going to give you feedback if you ask for it. So we can take some responsibility because we only have three years to learn how to do this. And it's kind of our responsibility to make sure we get all that we need before we go. And Katie, can I add something? It's very important to take home today that the endoscopy, if you are injured, it's not your fault. And so that's really important to know. And that's a really important take-home that it's not a taboo, first of all, that you can't ask for dials or any extenders or anything else that's available. But also that the injury is not your fault. It is a bad design scope. And we are doing our best to mitigate whatever forces that are generated through it. So I think that's another take-home message to all the fellows as well, who might be even struggling from an injury as we speak. Thank you. I think that's music to my ears, all that's been said tonight. But I especially appreciate that. Well, a huge thank you to all of our content experts for coming to join us tonight to learn how to protect ourselves and our teams in the endoscopy unit. Thank you to Dr. Fishman, Dr. Shergill, Dr. Pawa, and Dr. Raju. I've learned so much. And I'm sure that all of you have as well. And please feel free to reach out to us with any questions. Thank you for inviting me. Thank you, Doug. And thank you, Dr. Raju. Thank you, Katie. Thanks, Bobby. Thank you. Thank you, everybody. Thanks to our GIF fellow moderator and to our content experts for tonight's presentation. Before we close out, I want to let the audience know to check out our upcoming ASGE educational events and to register. Visit the ASGE website for the complete lineup of the 2024 ASGE events. The next Endo Hangout session will be Optical Diagnosis. And that'll take place on Thursday, March 7th from 7 o'clock to 8.30 p.m. central time. Registration is open. At the conclusion of this webinar, you will receive a short survey. And we would appreciate your feedback. Your experience with these learning events is important to ASGE. And we want to make sure we offer interactive sessions that fit your educational needs. As a final reminder, ASGE trainee membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website to sign up. In closing, thank you again to our presenters for this excellent webinar. And thank you to our audience for making the session interactive. We hope this information has been useful to you. And with that, I will conclude our presentation. Have a wonderful night.

ASGE Endo Hangout

GI Fellows

ergonomics

repetitive strain injuries

mandatory training

institutional support

neutral postures

endoscopy-related injuries

ASGE guidelines

microbreaks

grip techniques

mentorship

ergonomic checklist