Can We Prevent Career Ending Musculoskeletal Injuries in Surgeons?

A recent review published in JAMA found that surgeons are at a high risk of sustaining work-related musculoskeletal injuries. It is safe to say the orthopaedic surgeons in my circle and I are not good examples of applying the knowledge we have about acute and chronic overuse injuries to ourselves. I personally believe this is part of our extremely negative healthcare culture that leaves no room for self-care. What if we started encouraging best practices in musculoskeletal health and ergonomics for all surgeons? In this article, we are going to explore some of the findings of the JAMA review article and offer some tips for surgeons to reduce on-the-job musculoskeletal injuries.

Musculoskeletal Injuries

Acute

Performing surgical procedures does not often result in acute injuries, mainly due to a more present focus on surgical safety. That being said, most surgeons I know are able to share many stories of acute injuries they have sustained. Even with these events, the pervasive opinion would be that these things are inevitable, and if there is no harm to the patient, then no big deal. Needlesticks and other “sharp” injuries don’t usually involve the musculoskeletal system. However, each tool we use in surgery carries a risk of harm. Every time we lift a patient, we place ourselves at risk of injuring our neck, back, or shoulders in particular.

Acute on Chronic

At this point in my career, these are the most common. Every time I am asked to assist in the transfer of a patient to the operating table, I comment that I will do my best and that it might impact my performance of the surgery when it really matters. Rarely does anyone understand and few even care. However, on occasion, these moves lead to an increase of my baseline back pain, and at a minimum, risk causing distraction and delay in performance of the procedure. I have also performed plenty of operations where I need to hold a steady, sometimes awkward position, and I can feel a worsening of baseline numbness or tingling in my hand/arm or my foot/leg. Believe me, I am not unique. I know many surgeons who have rotator cuff problems, “tennis” elbow, wrist or thumb arthritis, and so on, where almost every move they make causes pain. We “learn” to endure and sometimes modify, but what if we could learn to prevent, mend or perhaps recover from these injuries.

Chronic

For surgeons, most musculoskeletal injuries are caused by standing in static (often uncomfortable) positions for long periods of time and performing repetitive motions during procedures. This, coupled with the fact that many surgeons wear heavy lead aprons, awkward headgear, and other equipment can lead to overuse injuries. Over time these factors can build and cause repetitive stress injuries like carpal tunnel syndrome, arthritis, and more. My goal is to raise awareness, so that most of our younger and future surgeons can either prevent or at least lessen the damage from our noble work. One effort to raise awareness was our web-conference, Ergonomics: Best Practices for Longevity. Thus far, personally, I have been successful in managing my chronic injuries with some physical therapy and a lot of yoga with core strengthening. My episodes of back pain are much less severe and much less frequent. What if you could avoid or stall musculoskeletal injuries significantly in your career?

Tips for Preventing Work Injuries

Here are a few simple tips to help prevent or delay these types of injuries at work:

• Stay in Shape - The better shape you’re in, the better you’ll be able to handle the physical demands of being a surgeon.

• Take Breaks - If you’ve got back to back procedures, try to take even a few minutes break to rest, take a walk or do a “mini” or 5-minute workout (cross-training) before heading back into the OR.

• Stretch - Doing simple stretches before, during, and after a long procedure can significantly help avoid injury.

• PRACTICE Improvement for Injury Management - We recommend taking on the complex problem of injury management in surgeons with our PRACTICE improvement methodology. Reflect on your injury situation with our 8 PRACTICEs checklist to either get back in the game sooner with the least harm or stay in the game longer. Make a plan with realistic goals. Intentionally adjust your surgical practice to recover well. Repeat until Well! Try the SurgeonMasters Performance Improvement Tool to assist your recovery. Check it out here.

SurgeonMasters

At SurgeonMasters, our goal is to provide surgeons with the tools they need to build sustainable practices. We offer a variety of educational materials including regular blog articles, podcasts, webinars, and in-person meetups. We also deliver surgeon and physician coaching to individuals and teams to power improved performance inside and outside the OR. Contact us today to learn more about our offerings, or join our mailing list to stay up to date with the latest from SurgeonMasters!

Source: Epstein S, Sparer EH, Tran BN, et al. Prevalence of Work-Related Musculoskeletal Disorders Among Surgeons and InterventionalistsA Systematic Review and Meta-analysis. JAMA Surg. 2018;153(2):e174947. doi:10.1001/jamasurg.2017.4947

The Straw that Broke the Camel's Back

“A series of irritating occurrences that eventually lead to one final thing that causes a person to lose their patience or react in a strong way.” 

Sounds a lot like post-traumatic stress or burnout to me!

Everyone’s life experience is different, but you might be able to relate to mine.

In my first full-time job as a surgeon, the irritating occurrences were many. In one very difficult operation, a surgical device attached to the patient’s femur trapped my hand with an excessive amount of force. A scrub nurse trying to assist me inadvertently increased the force on my fingers. Over the next minute, which felt like ten, I finally released my hand just before I would have passed out. With the assistance of the residents, we proceeded to complete the surgery, and the patient’s outcome was good. In our system of training and practice, I never would have considered taking time off for an injury such as that.

How about the time I sustained a needlestick injury during suturing a wound on a patient that was Hepatitis C positive? The future wonderful news that both my positive and the patient’s positive screening tests were false positives did not seem to allow a full recovery from the stressful decisions that I had to make regarding very high-risk anti-viral drugs for myself, as well as the risks to my wife and our sex life.

My job also had lots of unreachable dangled carrots. In addition, the inefficiencies in providing quality patient care and associated emotional challenges were numerous. One time, I was accused of Medicare fraud by the mother of a high-level physician administrator for whom I bent over backward taking over the care of her wrist fracture treated four weeks earlier in another state. I converted a plaster splint to a removable wrist brace, which had the same CPT code and led her to believe Medicare was being billed twice. The brace company and I both had to eat the cost of care on that one, but the harder pill to swallow was that the patient and her son never appreciated the lack of fraud. In another instance, we were accused of malpractice by a patient who had tremendous muscle disruption of the gastric muscle from the 2000 or more pound object that fell on his leg. At the time of fasciotomies, he had no muscle ischemia for an early compartment syndrome. He felt he could not work more than 8 hour days or run on the treadmill the same after a year. He sued and the university settled because the nurse had not adequately documented the notes while in pre-op.

Despite these events that could easily lead to paranoia, I have remained completely dedicated to the welfare of my patients. What is best for my patient? How can I see that my patient receives the care that they need? What can I do to provide my patient with the most straightforward path to recovery? Unfortunately, one day, when I saw my patient being blocked from surgery, it was the straw that broke the camel’s back. My sudden reaction brought out a lot of negative energy. This uncharacteristic, as well as unacceptable, behavior, resulted in some anger management counseling as prescribed by the hospital administration. As this was the first event in my file, I was able to recover my job and my career. Interestingly, the comments provided to me and my superiors after this event included signs that I was burning out. While I accepted responsibility for my actions, the overall system did not change. No one offered assistance for burnout. No one actually seemed to care. And I kept performing at the high-stress level expected of someone in my profession because the system doesn’t offer reciprocity in its relationship with physicians. The system gives very little, and it takes a tremendous amount from us.

Camels are amazing animals capable of surviving the very harsh conditions of the desert. In particular, they are able to go for a long period of time without water.  When they do drink, they can drink up to 20 gallons or more.  Like the camel, the surgeon appears to be sustainable with very little self-care. The surgeon trains to handle limited energy, some amount of sleep deprivation, high adrenaline situations, several thousand pieces of straw, and other adverse conditions like the barren desert with very little water. Surgeons are capable of going a very long time without normal wellness efforts and activities. Or so we think. We adopt the old adage of “don’t fix something if it ain’t broke.” But why don’t we try to fix something before it breaks? Before it burns out. How do we know what will be the final straw? How can we prevent the break before it occurs?

Through the evolution of the surgeon and adaptive training, the surgeon and physician learns to carry every increasing burden. The system continues to put more and more straw on our backs. We are expected to carry the straw longer distances.

Now I have choices. I choose how much straw I am willing to carry. I also choose to drink lots of water. We also have a choice to change the system, so that we do not overload our physicians and we provide wellness to both patients and our colleagues.

If not, eventually not enough wellness and just one more burden will be the straw that breaks the camel’s back.

At SurgeonMasters, we are committed to helping physicians struggling with burnout. We offer coaching services, wellness programs, podcasts, webinars, and much more aimed at arming physicians with the tools they need to thrive in their careers.

Contact us today to learn more about our programs and join our mailing list to get regular updates.

Addressing Physician Suicide

At the 19th Annual Chicago Orthopaedic Trauma Symposium, Dr. Pamela Wible presented data and findings from studying physician suicides. You cannot imagine my excitement! Am I crazy to be excited about physician suicide? These events are devastating to me! Rather I am excited that my friend and colleague Dr. Matthew Jimenez invited Dr. Wible to his annual course to share her ever expanding experience with perhaps one of the most challenging topics in medicine. I am excited that our profession may be starting to listen and heed what she is uncovering. In this article, I’d like to examine some of Dr. Wible’s findings and how we can use them to raise awareness, and hopefully prevent future physician suicides. 

What Factors Lead to Physician Suicide?

First things, first – I have always argued that suicide can be both irrational and rational. What causes physicians to take their own lives? From studying over a thousand documented cases of physician suicide, Dr. Wible has discovered several potential causes and/or risk factors. Here are a few of her very important findings which I find very relevant to surgeons:

• Many physicians know a colleague who has committed suicide. On top of that, those who are affected are not allowed to grieve. What if we demanded time, resources, and opportunities for our colleagues to grieve?

• “Happy” Doctors commit suicide too. Physicians who appear to be happy and well-adjusted are not exempt from the dangers of burnout and suicidal thoughts. Many physicians are experts at disguising their emotions and putting on a good face. If we don’t know who is overwhelmed, suffering, or risk of choosing suicide from their outward appearance, what if we assumed we are all at risk?

• Patient deaths & mistakes haunt physicians. When a doctor makes an honest mistake, or loses a patient (even if it wasn’t their fault), they are often haunted by it for the rest of their lives. What if we focused on adult learning theories such as growth and constructive feedback rather than punishment and controlling of others.

• Physicians experience post-traumatic stress and can develop symptoms of PTSD. While early research suggests that we experience secondary stress through our patients’ traumatic events, I have observed that we experience our own significant primary stress as victims of bullying, physical, mental, emotional and sexual abuse, and the patient death and patient harm.

• Malpractice suits can have a serious impact. Everyone makes mistakes. But when a physician makes a mistake, they are quite publicly shamed in court and in the media. What if the majority of lawsuits result from a misunderstanding rather than a mistake?

• Ignoring the problem only makes it worse. Sweeping physician suicides under the rug is only going to make the problem worse.

Preventing Physician Suicide

There will be additional lost lives. However, I don't think it will be in silence. These issues are real. Now that people are listening we need to continue to highlight possible solutions.  Here are some of the simple steps we can all take to help prevent physician suicides:  

• Expect mistakes and train for them

• Work to prevent bullying, such as stepping in to defend or deflect

• Encourage physicians to either seek mental health care or utilize confidential coaching resources

• Set up a “Buddy” system for all physicians

• Build a life outside of your practice with friends and family

• When it comes to whistleblowers and bullies, don’t remain silent. At least have a private conversation of potential support.

• Talk about physician suicide openly and amongst our peers

If you or a colleague have any of the risks for burnout or suicide, please contact Pam,  another coach, or me. If you or a colleague you know is having suicidal thoughts, please reach out now for help. 

Suicide Prevention Lifeline

American Foundation for Suicide Prevention

Physician and Medical Student Depression and Suicide Prevention

Pamela Wible, MD

Source: 33 orthopaedic surgeon suicides. How to prevent #34.

Seeking Help for Something Rotten

A recent article - “There is Something Rotten Inside the Medical Profession” - written by an anonymous physician and published on kevinmd.com, discussed the issues in the medical profession that can lead physicians to burnout and suicide. During my first 5 years in practice alone, I knew three physicians who committed suicide at my institution. One was a renowned burn surgeon who seemed, from a distance, superhuman - respected by patients, peers and trainees alike.

These experiences impact me deeply in many ways. I imagine their lives and experiences as surgeons were much like mine. Early in my career, I did not know what to make of it. At the time, I knew I was pretty unhappy, and I started getting a sense that I would rather get out than feel stuck in a job that could lead to me taking my own life. Now that I have been studying the issue for several years, I am much more knowledgeable on the causative factors.

Seeking Help

Many doctors of all generations and at all points of their career feel they do not have many options. Often the feeling is if we admit to suffering or struggling, WE are the outlier. Simply wanting to talk to someone or seeking help suggests weakness or failure.

According to the article:

“Medical training has long had its culture rooted in ideals of suffering. Not so much for the patients — which is often sadly a given, but for the doctors training inside it. Every generation always looks down on the generation training after it — no one ever had it as hard as them, and thus deserve to suffer just as much, if not more. This dubious school of thought has long been acknowledged as standard practice. To be a good doctor, you must work harder, stay later, know more, and never falter. Weakness in medicine is a failing, and if you admit to struggling, the unspoken opinion (or often spoken) is that you simply couldn’t hack it.”

Surgeons, physicians and trainees voluntarily seeking help is very rare. There is a sense that if we do, there are potentially career-threatening consequences that await us. How does one go on when your lifelong dream is over? Mandatory reporting programs further discourage physicians from seeking help. If you don’t seek help, there is nothing to report.

How can we expect physicians to seek help if the system is set up to fail them? More importantly, how can we help each other?

What are Potential Positive Steps? 

Let’s look at four potential positive steps we can take to improve the practice environment for physicians.

1. Stop the shame and stigma. We are all human. Burnout is not a weakness, but rather a symptom of chronic and/or acute injury or abuse. Show compassion to your peers.

2. Remove mandatory state reporting requirements. A mental health history should not disqualify anyone. Treated mental health issues are much much better than untreated and unrecognized. Current impairment may be an issue, but past impairment is not.

3. Offer mental health services to ALL health professionals and trainees.

4. WHAT IF all physicians were able to reach for support from psychiatrists, psychologists, coaches and others outside their institution or local environment to receive confidential assistance?

At SurgeonMasters, we are committed to helping physicians struggling with burnout. We offer coaching services, wellness programs, podcasts, webinars, and much more aimed at arming physicians with the tools they need to thrive in their careers.

Contact us today to learn more about our programs and join our mailing list to get regular updates.

Source: https://www.kevinmd.com/blog/2017/01/something-rotten-inside-medical-profession.html

Confronting Burnout In Our Communities

An article published early this year in the New England Journal of Medicine titled, “To Care Is Human — Collectively Confronting the Clinician-Burnout Crisis” lays out an argument for why burnout is an industry-wide problem and proposes options to start addressing these system-level issues. We may be tired of hearing the word “Burnout” or prefer a different word. More likely, we are tired of not moving forward. In this article, I propose three steps we can take today to confront burnout in our communities and move the ball forward.

Confronting Burnout

What can we do to stop the progression of burnout in our industry? Progress begins with working together.

According to the article: “The problem is not lack of concern, disagreement about the severity or urgency of the crisis, or absence of will to act. Rather, there is a need to coordinate and synthesize the many ongoing efforts within the health care community and to generate momentum and collective action to accelerate progress.” There is no doubt we need to address burnout at the system level. WE can take steps together at a local level today to make changes immediately.

Steps We Can Take in Our Communities

Step 1 - Raise Awareness

We need to continue to raise awareness around burnout, its causes, the symptoms, and how it affects each of us.  One of the many misconceptions surrounding burnout is that you’re either burned out, or you’re not. That’s simply not true.  

Burnout operates on a wide spectrum and it affects each of us differently in similar situations and circumstances. That is what makes burnout so difficult to “diagnose” -  we can’t order a biopsy to find out if the symptoms are benign. The feelings associated with burnout can crop up at times when we least expect and manifest in behaviors we never thought possible.  

Simply being aware that burnout is fluid and presents itself in each of us differently is an important first step. Let’s continue to have important, intelligent conversations around burnout to raise our collective awareness.

Step 2 - Act

Raising awareness is only the first step and amounts to little more than cheap talk if we do not follow through. We must follow-up our talk with action.

Here are examples of three actions we can take starting tomorrow in our hospitals, institutions, and practices:

• Peer-to-Peer Connection - Make connections with colleagues who are going through the same experiences you are. Sharing stories builds camaraderie and discussing solutions to similar problems can produce greater results with less stress and frustration. Find a group you trust and schedule regular meetings outside of the hospital to introduce a new environment.

• Wellness Day - Incorporate a “Wellness Afternoon” or morning, or whole day! Give your resident, fellow, or colleagues an afternoon off at least once a month to see the doctor, dentist or go for that long bike ride they’ve been craving. This builds in time for self health and takes a major source of frustration off our plate, with relatively low cost to the hospital. If you think it will hurt productivity or the bottom line, the data argues that productivity actually increases. Very few physicians actually take personal or sick time off, and this contributes to burnout, unless we encourage “wellness” days rather than “sick” days.

• Mindfulness Practices - Practice a form of mindfulness. Before you skewer this suggestion as just another lame meditation or yoga suggestion, hear me out. I encourage all of us to start looking at mindfulness with broader perspective. Mindfulness can be something as simple as a breathing technique before surgery, to something as elaborate as finding a creative outlet that improves active mindfulness. A great example is SurgeonMasters collaborator and orthopaedic surgeon, Jonathan Swindle, who described his love of car restoration as his creative outlet.

Step 3 - Support

The final step we must take is to truly support these activities at a leadership and institutional level. It’s not enough to simply offer encouragement or pay lip service to burnout prevention efforts. It is critical we devote the necessary resources to improving the health and well-being of our healthcare providers, and then provide support and encouragement. Let’s start working in our hospitals and communities at a grassroots levels to turn the tide on burnout.

SurgeonMasters delivers burnout prevention resources and wellness programs to educate, support, empower healthcare providers. Our signature program, WellnessEdge™, provides a strong foundation, including progressive strategies and forward-thinking action plans, to help surgeons thrive in their careers and personal lives. Contact the Team@SurgeonMasters for assistance starting a burnout prevention effort in your community.

Source: To Care Is Human — Collectively Confronting the Clinician-Burnout Crisis - The New England Journal of Medicine, Massachusetts Medical Society, Jan 25, 2018.