Pain is a silent companion to many gastroenterologists, with multiple survey-based studies reporting that endoscopists suffer from persistent pain in the thumb, wrist, neck, back and shoulder. I suffered through my pain for a few weeks until I couldn't take it anymore and then I went and saw somebody and I had to undergo physical therapy. We aren't immune to the repetitive stress injuries that other professions experience when using the tools of our trade. We had a colleague in her 30s who ended up having to already get orthopedic surgery because of wear and tear in her wrist and elbow. Over half of gastroenterologists have sustained an injury related to endoscopy and one in five have required time off to recover from an injury. Why? Our procedure days are packed without adequate rest between cases. Additionally, the rooms we scope in were not typically designed with the operator in mind. And while the optical technology of the endoscope has continued to advance, the design of the current endoscope has not changed much since the 1980s when the first video endoscopes were introduced. I was surprised to see it, even in one survey it said up to 80% of gastroenterologists had reported some sort of work-related injury. You don't need statistics to tell you what you probably already know. The pain is real and sometimes it doesn't go away. I've seen my colleagues who have tried to do the job despite what they're going through to the point that they ended up requiring major surgery and lots of time off to recoup. The good news is that there are solutions, most of which you can implement immediately. They are simple, easy to do, and can dramatically improve your ability to practice medicine. You need to be aware of those factors, those ergonomic factors, that we can change, we can correct. Should we sustain permanent injuries, it really can have a real impact on your career. We have to acknowledge as a field that this is something that is happening widespread. I think that there's a little bit of a culture of denial. It's not fun to talk about. I think it's more pervasive than we've known in the past. I think people just haven't spoken up, thinking that everyone else has done it, I have to do it too. This is a major issue. Amongst gastroenterologists and endoscopists, the idea of work-related stresses on our body has always been openly discussed, for instance, at meetings, but there's been very little guidance in how to address it. This room looks like a typical endoscopy suite, right? And that physician looks like your typical gastroenterologist. But what in this room is leading to the pain? First, let's take a look at that doctor. They're holding an endoscope and they're gazing at a monitor. But notice how they're doing those things. That monitor is well above eye level or off to the side, forcing their neck into sustained extension or extreme rotation. They're standing in one position and holding that endoscope up near their chest and sometimes down by their waist. Notice how much effort it's taking to maneuver the endoscope. Would you ever choose to stand like this for hours at a time? That's one thing I'm pretty conscious about telling our fellows. I see them contorting themselves into some weird pretzel shape and I tell them to stop doing that because they'll never be able to last a whole day as an endoscopist. Our studies have shown that holding the control section of the endoscope leads to significant wrist extensor loads, thumb flexor loads, and non-neutral wrist postures. Holding the insertion tube requires high pinch forces and is also associated with wrist extensor loads and non-neutral postures. We gastroenterologists take muscles and tendons and place them under heavy tension for sustained periods of time. It's easy to imagine what happens. These stresses lead to minor tears in the muscle fibers, the mid-substance of a tendon, or the emphasis, or tendon-bone interface, which cause inflammation, pain, and eventually injury. This is what we call microtraumatic injury, which is basically repetitive overexertion of the same muscle by engaging in static or repetitive tasks. Endoscopied microtraumas without adequate recovery over months or years may cause chronic pain, degeneration of the muscle tissue, and eventual disability. What I'd say to the younger resident is that you might be fine now and get away with it now, but when you get to 40, 50, and older, your body won't be able to cope with this and it will make your time doing endoscopy much less enjoyable and effective. I actually got interested in this field when I, myself, got injured last year and had a chronic use injury, so I started to learn more about it, what caused it, what were the risk factors, and then I started thinking, how could I have prevented this? If someone had taught me certain things, then maybe I wouldn't have had this injury so soon. Ergonomics, in its simplest form, is the study of how a given type of work affects people physically and mentally. It is the science of fitting the work to the person, not the person to the work. Athletes, they spent a lot of time training and getting really good at their sport, and then they actually do a lot of good preventive care. They do a lot of stretching pre and post, workouts or doing games, and as physicians, we actually don't do that, and we don't consider all the training time that we put into it, but there is that physical component that we need to take care of. There are some basic facts you need to know when it comes to ergonomics and endoscopy. The first is to understand that when you are scoping, your body is working. First, your forearm and hand muscles are working to generate the force required to manipulate the endoscope dials and the insertion tube. The maximum force that can be generated by a muscle is called the Maximum Voluntary Contraction, or MVC. Men usually have an advantage over women in this, because typically women can only exert 60% of the muscular force that men produce. This discrepancy is physiological. Men have more muscle mass than women, and the physiological cross-sectional area of the muscle fibers is the major determinant of the maximum force that can be generated. Since the amount of force required to manipulate the endoscope is fixed, women are essentially working physically harder than men to perform the same task. As an example, let's say that theoretically it takes 1 kg of thumb force to turn the colonoscopy dials. If the maximum thumb force of the average female doctor is 4 kg, then she will be working at 25% of her MVC to manipulate the dials. If the average male doctor has a maximum thumb force of 8 kg, he will only be working at 12.5% of his MVC. We are more prone to getting these injuries because of the scope design, I think because of our hand size, and so I think we need to be even more cautious, and we need to make sure we teach all the other women in our field this as well. That doesn't mean men are off the hook. The same principles of repetitive stress apply no matter how strong you are. The result is the same, but the timeline to an injury for women can be much faster. Men should be, even though you would like to think different, but I think they should be as worried because being able to bench press has got nothing to do with holding the scope right because you're not using those muscles. We're not just talking about injury, we're also talking about efficiency of doing the endoscopy, so they should be as cognizant of ergonomics. Avoiding injury has a lot to do with posture. Finding a neutral posture is key since it reduces tension on passive or non-contractile tissues like your ligaments and optimizes the length of your muscles so they can generate the greatest amount of force. It's all about neutral postures because when you talk about force production, our greatest ability to produce force is when we are in neutral postures, and so if you adopt anything besides a neutral posture, then you're at a mechanical disadvantage. So you're working harder unnecessarily. Each muscle group has an optimal position in which it can generate the highest force. For most muscle groups, optimal muscle length can be remembered by standing upright in anatomical position, but with the elbows bent at 90 degrees and the thumbs up. Working as close to this posture as possible optimizes your muscle strength, making the same task use relatively less effort. This helps us perform a task for longer before becoming fatigued. On average, your maximum grip strength reduces by 40% when your wrist is in 45 degrees of flexion and by 55% when in maximum wrist flexion. Your maximum grip decreases by 25% in strength when in 45 degrees of wrist extension. Additionally, consider that bending forward while standing, such as when the patient table is too low, increases compression on the lumbar discs by 50% versus standing upright. The same principle applies to the shoulders and legs. The overlying principle is really to make sure you have proper posture and a neutral position because the more neutral you are, then you're not overstraining or overusing the smaller muscles because what happens, I think, with these hand injuries is we don't realize the muscles that we're using or the movements that we're doing as much because it becomes so innate, we don't think about it. We also need to look at the other big contributor to fatigue, muscle recovery. Good posture will optimize muscle length and strength to help minimize muscle fatigue, but nothing is going to stop it entirely. Your muscles getting tired is simply a fact of life. You can only do so much physical work before they begin to fatigue. It's when we work through the fatigue that the problems begin to occur. That's one thing I tell my fellows all the time, that they have to stand in a position that they can comfortably stand in for the duration of the day, and they have to keep in mind to keep their arms and their hands in as much of a neutral position as possible. It's important to understand the physiology of muscle fatigue in order to appreciate why rest is necessary. The longer the muscles are contracted, the more time lactic acid has to build up. The rate of lactic acid buildup depends on the relative effort. As lactic acid accumulates, discomfort will increase. When muscles are finally able to relax and blood flow is restored, oxygen and glucose are brought into the muscle and the lactic acid is transported to the liver. Full recovery occurs only when the lactic acid debt is paid off. The proportion of work time to recovery time required to avoid fatigue depends on how much of one's strength, or maximum voluntary contraction, the task requires. The more strenuous the task, or the longer the contraction is held, the longer the recovery time is. With some limitations, we can estimate the required recovery time for endoscopists based on work recovery curves. Assuming the force required to handle the endoscope is light or very light, the static grasp of the endoscope for three minutes, such as during an upper endoscopy, will require three minutes of recovery time. But a seven and a half minute procedure would require a recovery time of 45 minutes. Given that the mean duration of a colonoscopy is 22 minutes, and the median relative effort during a colonoscopy is 15 to 25 percent of MVC, the recovery time is off the charts. Additionally, there is plenty of research to show that prolonged static standing can have negative health consequences, including increased musculoskeletal discomfort, swelling of the lower extremities, and even an increase in your risk for cardiovascular strain. We are trying to prevent something which will happen years down the line, and people don't want to see that far ahead. They say, I'm doing fine right now, especially people who have been doing things a certain way and have not had injury. Those will be the ones which will be most difficult to change because, and it's important because they will be teaching the other people. We know you aren't going to see less patients, and you can't spend half your day relaxing. If you could do those things, you would already be doing them. When I come in on a Monday, I know I'm going to have anywhere from six to ten complex endoscopy cases waiting for me. There's no time in between. Gastroenterology is unique for the volume of patients that are coming in. Gastroenterology is unique for the volume of procedures we do. A busy endoscopist may do anywhere between ten to twenty cases in a whole day. But it's estimated that more than a third of gastroenterologists take no breaks, no breaks at all during their work day, and less than half take only occasional breaks. And when was the last time you worked an eight-hour work day? The volume of endoscopy people have done has just gone up dramatically due to increased pressures to do more screening colonoscopy, declining reimbursements that led people to want to do more procedures in the same period of time to maintain their reimbursement has led to a cumulative toll now catching up with people. There's been a focus on efficiency in the endoscopy suite, increasing RVUs and productivity in the endoscopy suite. And all that happens at the expense of physicians doing more procedures with less time. And I think all of that leads to sort of worse physical outcomes. In sort of the changing healthcare systems, people are expected to do more endoscopies in the same amount of time to be able to, you know, meet whatever targets that they're supposed to. So I think the additional stresses of having more procedures that need to be cranked out in the same amount of time is probably also sort of magnifying the picture because people are having the repetitive injuries a lot earlier. We know you are not going to schedule less patients during the day. But keep in mind that when you are injured, you can't see any patients at all. Don't let your sense of duty get in the way of your effectiveness or ability to practice in the long term. A healthy doctor can see many more patients over their lifetime than an injured one. Instead of going and doing my procedure note right away, I jot down the notes for my procedure note and I do my hand stretching in between cases. And at the end of the day, I may go finish the procedure reports. It's still a challenge and I'm still balancing that challenge. We have now adopted a predominantly split endoscopy schedule where an endoscopist who does procedures in the morning will do office or something else in the afternoon and vice versa. You would office in the morning, scope in the afternoon with the idea of not having long days of endoscopy, especially day after day. If we can figure out a way to have a break day in between two hard days of endoscopy, that break day where you're not doing a procedure but seeing patients in the clinic would give you rest to your body and allow the body to recover. So planning your week is also critical. There are some things you can optimize in your endoscopy unit today to help minimize your risk of strain and injury. When we are designing endoscopy suites, we want the suite to be flexible enough to accommodate 90% of the population, from the smallest 5th percentile female to the tallest 95th percentile male. In our previous endoscopy unit, we had fixed monitors at the corners of the wall which ergonomically speaking was not very helpful and obviously I would be craning my neck all day to actually look at the monitors. So one modification they did make was that all the monitors are now in a movable boom so we can actually modify the location as well as the height of our monitors. The most important thing you can do is adjust the height of your workspace to fit your body. Change that table height so your shoulders, back, and arms are in a neutral position, Generally at or slightly below elbow height. In order to accommodate most endoscopists, the table height should be adjustable from 85 to 120 centimeters. Move those monitors down on the wall so that your body doesn't have to strain to allow you to look at them. Your head should be in neutral posture with a resting eye position falling to the middle of the screen, which means that the viewing angle should be 15 to 25 degrees below the horizon following your eyes natural gaze. In order to accommodate most endoscopists, the monitors should be adjustable from 85 to 120 centimeters. In order to accommodate most endoscopists, the monitor should be adjusted to a height in the range of 93 to 262 centimeters. If the monitor is too high, you might find yourself in cervical extension or looking slightly upward. If the monitor is too low, you will find yourself hunched forward to view the screen. The viewing distance will also be variable depending on the monitor size and physician preference. But generally, the monitor should be placed between 52 and 182 centimeters from the endoscopist. If you are peering forward to see the monitor, be sure to bring it closer. Headaches and eye fatigue are common signs that the monitor may be too close. This is a good time to talk about glasses. Some of us use bifocals. However, looking through the bottom of bifocal lenses can put your neck in extension, a compromising position. Consider the use of dedicated monofocal lenses. They make it easy to see the monitor at a distance while maintaining a neutral neck position and gaze. When in static standing postures for long periods of time, find ways to make your standing posture dynamic to keep the blood flow going to your lower extremities. One way to achieve this is to vary your stance regularly. Stand with your feet shoulder-width apart. Then stand with one foot in front of the other. Change your stance so the opposite foot is in front. Consider a footrest or a low stool so that you can easily put one foot up to change your stance. Standing still for a long case can lead to pain and fatigue, so mindfully changing your stance increases blood flow and reduces fatigue. Also consider using anti-fatigue mats. While there is not data specifically for GI endoscopy, a prospective randomized trial demonstrated that use of gel pads during laparoscopic surgery improved foot pain, overall amount of discomfort, and energy level. As would be true in the OR, mats would need to be cleaned and processed between cases. Studies have also shown a benefit from the use of cushioned insoles for reducing discomfort and fatigue, with the greatest benefit occurring after several hours of prolonged standing. An important caveat, there has been no demonstrated benefit for preventing back pain with insoles. Compression stockings give support throughout prolonged standing tasks. Most studies demonstrate improvement in the subjective complaint of leg fatigue, pain, and swelling with prolonged standing, with the most pronounced benefit in workers with chronic venous insufficiency. When you are not performing procedures, it is still important to incorporate good ergonomics. For example, when you are working at your desk, make sure you follow the same computer monitor guidelines previously described. Typically, monitors should be at an arm's reach, slightly further as the monitor gets larger. Every effort should be made to have neutral wrist posture while typing, which can be achieved by using a split keyboard or approaching a straight keyboard at an angle. Be sure to find a comfortable mouse for you, since the right mouse differs for different people. A wireless mouse is usually best. To choose the right chair, make sure that your feet are supported on the floor and that only two to three fingers of space exists between the edge of the seat pan and the popliteal fossa. Your hips should be slightly higher than your knees to facilitate a neutral spine when sitting upright. However, sitting in a reclined position with proper back and upper extremity support is also acceptable, assuming you can still see the monitor without peering forward. Reclined seating is also an excellent position when speaking on the phone. Regardless of whether you are upright or reclined, be sure the seat back is adjusted to support your back and that your arms are supported by the desk or armrests. And remember to take frequent breaks. We also need to discuss the gastroenterologist's best friend, the endoscope. Almost half of gastroenterologists reported that they felt their hands did not fit the endoscope control head. Over 60% reported that their hand size impaired their ability to perform an endoscopy. One of the things I've learned is there's actually an extender that one of the device companies makes that you can put on the small wheel, so it does help with the extension of the thumb motion. A pilot study evaluated the use of an angulation dial adapter for hand spans less than 19 centimeters. The investigators concluded that further evaluation of endoscope design may reduce hand fatigue and injury given the angulation dial showed a trend towards decreased procedure time in physicians with small hands. And even if you don't fit into these categories, learning how to hold and operate the endoscope in neutral position will cut down dramatically on preventable injuries. During long cases, we are not only standing, but holding that scope for a prolonged period as well. Try to take a mini break in the middle of the task. Put down the scope, shake out that hand, get the blood flowing again. Rest the hand if you can during the procedure to minimize the static load. Try and do this before you're feeling muscle pain. Allowing your arm to rest, letting the blood flow come in, relieve that lactic acid load that's developed there. You know, giving my hands a couple of squeezes to make sure I have fresh blood flowing through. That can help to relieve some of that discomfort during the endoscopy. When holding the scope, think about those neutral postures and minimize the forces you are producing to manipulate the control section and the insertion tube. By keeping the scope straight and soft throughout the procedure, we are maximizing our ability to apply tip deflection with minimal force. There is no one way to hold the scope. We all have had to figure out a way that works for us. I'm holding the scope in a more neutral position. My shoulders are relaxed, my arms are not, you know, bent too much. I'm in neutral position. If I have to make a turn, I sometimes will probably turn my body a little bit, but I try not to cross the midline as much as possible. I try to hold it in this position where it feels the most comfortable to me, and I feel like I'm not putting extra stresses on my wrist or my finger more than it has to based on sort of the weight of the scope. For many of us, everyday endoscopy includes ERCP. With the added load of the lead apron, it becomes even more important for us to think about ways to minimize injury, strain, and fatigue. For the endoscopist who uses fluoroscopy in their practice, it is important to take steps to maximize protection against ionizing radiation. Average effective doses of approximately 2 to 70 microsieverts per procedure have been observed for endoscopists even when wearing lead aprons. As physicians, our first thought regarding radiation exposure is increased cancer risk. It is estimated that a radiation dose of 10 millisieverts will increase the risk of developing cancer by 0.1% and fatal cancer by 0.06%. Recent publications, mostly from interventional cardiology, have raised concern for brain tumors. There is significant uncertainty but increasing concern for ionizing radiation leading to circulatory disease as well. We are so focused on cancer risks that we forget about a known and established risk, cataracts. The lens of the eye is one of the most radiosensitive tissues in the body. For age-related cataracts, posterior subcapsular location is the least common site, but it is the site most frequently associated with ionizing radiation exposure. The mechanism of radiation-induced cataracts is not known. Theoretical mechanisms include genomic damage resulting in altered cell division, transcription, and abnormal lens fiber cell differentiation. In April 2011, the International Commission on Radiological Protection published a statement on tissue reactions. The threshold in absorbed dose for radiation-induced cataracts is now considered to be 0.5 grays. The ICRP recommends an equivalent dose limit for the lens of the eye of 20 millisieverts. How many ERCPs is that? A recent study evaluating an intervention to reduce the risk of radiation exposure during ERCP estimated that endoscopists performing 100 ERCPs per year receive a cumulative dose of 21 millisieverts at the eye, which is equivalent to approximately 700 x-rays. Endoscopists performing 500 ERCPs per year receive an estimated cumulative dose of 105 millisieverts to the eye. There's one thing that I think we don't talk about enough is what should be an optimal fluorotime for a simple case because people don't have standards and guidelines to go by and that's one thing that we can do a little bit better. For high-volume endoscopists, the use of lead glasses and use of additional radiation shielding is imperative. How do we monitor radiation exposure? The dosimeter. Personal dosimeters to monitor radiation exposure are a must. High-volume ERCP providers should consider using two dosimeters. The International Council on Radiation Protection recommends that one dosimeter be worn on the trunk of the body inside the apron and the other worn outside the apron at the level of the collar or the left shoulder. The badge on the trunk of the body inside the apron estimates whole body exposure. The collar badge estimates the dose to the surface of the unshielded skin and the lens of the eye. Together, the two badges can be used to estimate the effective dose. It makes sense that we can reduce the probability of a radiation-induced cancer by minimizing radiation exposure. The guiding principle of radiation safety remains the acronym ALARA, as low as is reasonably achievable. To achieve ALARA, the critical components of fluoroscopy are time, distance, and shielding. Reducing fluoroscopy time and dose rate will decrease overall exposure time. By doubling the distance from the source, radiation exposure is reduced to one-fourth of the original dose. Radiation protection equipment includes equipment or table-mounted drapes or shields, personal protected devices including lead aprons, thyroid shield, and eyewear. A double-blind, randomized sham control trial of the addition of a radiation-attenuating drape around the image intensifier during ERCP significantly reduced radiation exposure to endoscopists and staff by 90%. Aprons can be one-piece, two-piece, or pregnancy-sized. The weight of the aprons can be a problem. Studies investigating this issue concluded that there is a positive correlation between the use of lead aprons and lumbosacral spine disorders. One of the procedures I do a lot of is ERCP procedures. There's a lot of experience even with endoscopists who've been performing those types of procedures of having difficulty with their back, for instance, or their neck, and people needing neck surgery. A biomechanical analysis of a radiologist wearing a 15-pound, one-piece lead apron demonstrated a force of 300 pounds per square inch on the low back, which is reduced by 80% with the use of a two-piece lead apron. The International Commission on Radiological Protection recommends the use of two-piece, skirt-type lead aprons to help distribute the weight. Some newer aprons are lightweight while maintaining lead equivalents and are designed to distribute weight through straps and shoulder flaps. Lead aprons are heavy. We worked with the company to get the most lightweight lead that provides us with the full protection, and for us, we actually get custom-fitted for our leads. When wearing a lead apron, it is even more important to place the monitors in front of the endoscopist at the proper height to avoid neck extension or lateral rotation. Here's an example of how improper positioning of the monitor can lead to added neck and shoulder strain. Always think about the positioning of the monitor and the bed so that the body is in a neutral position. Most hospitals have a radiation safety officer. Reach out for help to understand how you can optimize your situation. What cannot be stressed enough, only you know what is most comfortable to you. Dr. Grace Alta, a world-renowned ERCP endoscopist, wears a one-piece lead apron with a belt buckle across her chest because this is what is most comfortable for her. You know your body best. The International Atomic Energy Agency has free and downloadable resources available on its website, including the poster 10 Pearls, Radiation Protection of Staff During Fluoroscopy. These resources are provided as a public service. We've collaborated with Dr. Raju at MD Anderson, and now Kusasaki, a ballerina in the Houston Ballet and gyrotonic expert and instructor, to compile a series of exercises that we think can help the body rest and reset between procedures. Gyrotonic exercise sequences are composed of spiraling, circular movements which flow together in rhythmic repetitions with corresponding breath. Each movement flows into the next, allowing the joints to move Each movement flows into the next, allowing the joints to move through a natural range of motion without jarring or compression. These sequences create balance, efficiency, strength, and flexibility. Greetings. My name is Raju. I'm on faculty at the University of Texas MD Anderson Cancer Center. And today, I have the distinct honor of introducing my colleague, Dr. Minaz Shafi. Minaz is full professor at the University of Texas MD Anderson Cancer Center with a special interest in GI and motility disorders. And she's also passionate about preventing occupational injuries in endoscopists. Recently, she has played an active role with the American Gastroenterology Association in studying this subject further. Minaz. Thank you. As endoscopists, we are at risk of work-related musculoskeletal injury. Today, we will show you some simple techniques that can minimize muscle strain. Before you start any procedure, first, do an ergonomic timeout. Take time to position yourself optimally with regards to your patient and your equipment such that you are standing in a neutral position. During the course of your workday, take micro breaks. Micro breaks are small, couple-of-minute breaks every hour, hour and a half that help in preventing muscle fatigue. During these micro breaks, you can perform simple stretching exercises that can prevent muscle strain. Thank you, Minaz. Let me introduce Nao Kuzusaki. Nao is a professional ballerina with a special interest in occupational injuries and how to prevent them. Nao. Being a ballet dancer and gerotonic exercise coach, I understand the importance of maximizing the functionality of the entire body. One of my passions is to share with you that through these simple exercises, you can improve the productivity in the workplace and help prevent injuries in the long run. Now, let's get started. Once the procedure is over, we will start the first exercise using the rubber gloves. Take the gloves halfway and pull them apart. Widen the elbows and the shoulders. Hold for a few seconds, then release. Keep the shoulders down and activate the core at the same time. Now, bring your hands overhead and bend side to side. Bending at the waist, expose the armpits and open the side body. Come back to the center and lift the shoulders to the ears. And release. Up to the ears and down back to shoulder. Release. If the gown is clean, use this opportunity to reactivate the fingers. Roll the gown into a tight ball and squeeze them together. And release. Repeat this as many times as time allows. While washing your hands, release the tension in your shoulders with shoulder rolls. Start by rounding the shoulders, then up to the ears. Bring them back down. Start by rounding the shoulders, then up to the ears. Bring them back down. In this next exercise for a full body check-in, keep the rubber band in your endoscopy suite. With rubber bands taut, bring them overhead and behind the ears. Open the chest and release. Expose the sternum to the ceiling and stretch out the shoulders. Before exiting the suite, use the wall for a backstretch. Prepare the body into a push-up position. Bend the elbows, straighten and curl back. Keep the body in a plank. Curl the body back into the spine and abdominals pressing into the back. I hope you found this session useful. If you have any issues with your body mechanics, make sure you seek the counsel of a personal trainer. Thank you. Here is a summary of the post-procedure stretching exercises to consider implementing. Periscapular stabilizing exercises will stretch the shoulder muscles and activate the core. Remember to use clean gloves. Continuing to grasp the gloves, raise your arms overhead for the shoulder release and side stretch exercise. If the gown is clean, roll the gown in a tight ball and squeeze, then release the gown to reactivate the fingers. When washing your hands, roll the shoulders forward, then backwards in large circles. A full body check-in can be performed using a rubber band, which should be easy to store in your room. Raise your arms overhead, look up towards the ceiling, and move your arms apart to stretch your shoulders and trunk muscles. Before you leave the room, use the wall to perform back stretches. Place your hands on the wall in push-up position. Keeping your abdominals tight, perform a wall push-up by bending the elbows and letting your scapula move towards your spine, then straighten the elbows and curl the back so your scapulas move away from the spine. To be at the top of your game for your patients and to have a long and fruitful career in medicine, it's imperative that you pay attention to the messages your body is sending you. Take the time to do an ergonomic time-out before all of your procedures. If you work at a hospital, there often are ergonomists available to help and consider requesting a personalized consultation. Don't wait until you're serious about your surgery. If you're not sure if you're ready for it, you can always ask for a personalized consultation. Don't wait until you're seriously injured or have to take significant time away from your practice to recover. Don't wait until it's too late. We need to learn how to take care of ourselves as physicians. We spend our entire life taking care of other people, but we forget sometimes to take care of ourselves. People going into this field need to realize that they need to take care of their bodies. Their employer may not necessarily do that, may not be aware of the issues. They need to advocate for themselves, and they need to do it early on. They shouldn't wait until they're having issues. The idea that just deal with it or don't say anything or, you know, don't worry, you'll figure it out, that's all bad advice. I think that we need to think about it. We need to make changes personally so that we can make sure that when we're interacting with the endoscope, we're trying to minimize our own strain, making sure that we're working in as neutral a posture as possible. And in order to do that, we have to talk about it. We have to make sure that our physicians are educated about it, and we have to provide them with the tools to be able to do that. If you feel like you need more help, get in touch with us. The ASGE is here to help. Thank you.

musculoskeletal injuries

ergonomics

endoscopy

repetitive strain

posture adjustments

workspace setup

ergonomic tools

muscular health