Presentation
A survey study on the effects of surgical modality on surgeon wellness: workload, neuromusculoskeletal symptoms, and burnout
DescriptionAdvances in surgical technology and technique have improved patient outcomes and allowed for more complex, minimally invasive procedures. Despite these innovations, the prevalence of neuromusculoskeletal disorders (NMSDs), pain, and physical discomfort reported by surgeons has increased in the past decade (Epstein et al., 2018; Stucky et al., 2018). This “impending epidemic” (Park et al., 2010) negatively affects surgeon wellbeing, daily life (e.g., sleep) (Wohlauer et al., 2021), and career longevity and productivity. Previous studies have demonstrated almost 50% of surveyed surgeons feel that physical discomfort could negatively impact surgery performance and restrict career longevity (Wells et al., 2019; Wohlauer et al., 2021).
Due to the increasing prevalence of work-related injuries reported by surgeons, there is a critical need for an improved ergonomic understanding and interventions in the operating room. One unanswered question is “do surgeons’ preferences for specific surgical modalities (e.g., open, laparoscopic, endoscopic, robot-assisted (robotic)) affect the incidence of NMSDs, pain, and physical discomfort? As each modality is associated with a different operative posture and orchestration of instrumentation, it warrants further analysis to determine if any of these surgical modalities are ergonomically protective or harmful for surgeons. This study sought to evaluate and compare surgeons’ wellness among four surgical modalities (endoscopic, laparoscopic, open, and robot-assisted). The study focused on thoracic and abdominopelvic surgeons due to the variety of surgical modalities they frequently utilize in their surgical practice.
This study was approved by the Institutional Review Board (IRB) of an academic hospital. The inclusion criteria covered all urologic, gynecologic, thoracic, and general (including breast, colorectal, hepato-pancreato-biliary, and bariatric) surgeons across all geographically distinct parts of this academic hospital system in the United States. An electronic survey using Qualtrics (Qualtrics, Provo, UT) was sent to the surgeons. The survey consisted of questions regarding demographics, anthropometrics, surgeons’ practice time per surgical modality, physical and mental demand (from 0=Not demanding to 10=Extremely demanding, modified from Surgery Task Load Index (SURG-TLX) (Wilson et al., 2011)), neuromusculoskeletal symptoms including body part discomfort/pain (modified from standardized Nordic musculoskeletal questionnaires NMSQ (Kuorinka et al., 1987)), NMSDs, burnout and job satisfaction.
The effects of modality on dependent variables that were recorded per surgical modality were evaluated using either the non-parametric Kruskal-Wallis test and post-hoc non-parametric Wilcoxon Signed-Rank test (pairwise comparisons) or a logistic regression and Wald-based pairwise comparisons (dependent on the type of the data). The effects of surgical modality on dependent variables that were not recorded per surgical modality were evaluated after each surgeon was allocated to a dominant surgical modality. The threshold for defining a dominant modality was as follows: 1) the difference in the percentage of the procedural time a surgeon spent performing different surgical modalities were calculated, 2. If there was a surgical modality which its difference from the other three modalities was “at least 10% or higher”, the surgeon was allocated to that surgical modality. Then, similar statistical methods were performed. For all statistical analyses in this study, a significance level of 0.05 was considered.
The electronic survey was sent to 245 thoracic and abdominopelvic surgeons; 79 surgeons completed the survey (response rate 32.2%), including 19 urologic, 22 gynecologic, 3 thoracic, and 35 general surgeons. The average (standard deviation (SD)) of the 79 respondent surgeons’ anthropometrics was age 46.6 (9.3) years, weight 77.7 (14.6) kg, and height 174.1 (8.9) cm. Thirty-one surgeons (39%) were female surgeons. Of the 79 respondents, 65 surgeons (82.2%) had a dominant surgical modality: 10 endoscopic, 15 laparoscopic, 26 open, and 14 robotic surgeons.
All surgeons were asked if they ever had or currently have neuromusculoskeletal pain. Fifty-nine percent of the 79 surgeons (regardless of modality) and 62% of the 65 surgeons with a dominant modality answered “yes” to this question. The results revealed that this problem was less prevalent among robotic surgeons (21%) relative to surgeons with other dominant surgical modalities (69%-80%) (all p < 0.01). No significant effect of surgical modality was found for the response to a question asking, “Do you feel that any physical discomfort or pain you experience will influence your ability to perform surgical procedures in the future?” and 35 out of all 79 surgeons (44%), regardless of modality, responded “Yes” (3 surgeons did not wish to answer to this question).
Physical demand was the highest for open surgery (6.25 (±2.24)) and the lowest for endoscopic (3.68 (±2.19)) and robotic (3.78 (±1.78)) surgeries (all p<0.05). Open (5.43(±2.01)) and robotic (5.23(±1.79)) surgeries required the highest levels of mental workload, followed by laparoscopic (4.7 (±1.99)) and endoscopic (3.0 (±1.77)) surgeries, respectively (all comparisons of modalities were p < 0.05 other than when robotic and laparoscopic surgeries were compared).
Physical discomfort/pain after a day of surgical procedure in open surgeries (4.58 (±2.46)) was higher than endoscopic (2.65 (±1.92)), laparoscopic (3.7 (±2.37)), and robotic (2.88 (±1.71)) surgeries (all p < 0.05). The results of the body part discomfort/pain questions revealed that discomfort/pain (immediately after surgery) was lower in the shoulder for robotic surgeons compared to laparoscopic (p = 0.0174) and open (p = 0.0377) surgeons, but only in the left fingers for robotic surgeons compared to the endoscopic surgeon (p = 0.0109). The prevalence of NMSD was significantly lower in robotic surgeons (7%) compared to the other surgical modalities (between 60% - 67%) (all p < 0.05). Overall, 39 out of the 65 surgeons (60%) used at least one general intervention or strategy (e.g., over-the-counter medicine, changing position) to minimize their operative discomfort or pain. This included 80% of endoscopic, 73% of laparoscopic, 65% of open, and 21% of robotic surgeons. 13 out of 65 surgeons (20%) had sought at least one method of medical help (e.g., injections, physiotherapy) to minimize their work-related discomfort or pain (10% of endoscopic, 27% of laparoscopic, 27% of open, and 7% of robotic surgeons).
Seven questions recorded the surgeons’ job-related feelings on a 7-level scale, and the responses were simplified so that the first three levels (“Never,” “A few times a year or less,” “Once a month or less”) were grouped as “less frequent” and the last four levels (“A few times a month,” “Once a week,” “A few times a week,” and “Every day”) were grouped as “more frequent.” The nominal logistic regression revealed that surgical modality was significantly affected if surgeons felt burned out from their work (p = 0.0223), where laparoscopic and open surgeons’ responses grouped as “more frequent” to this question were higher compared to robotic surgeons; the odds ratios were 5.50 (95% CI- 1.06-28.42) for laparoscopic and 6.93 (95% CI- 1.53-31.38) for open surgeons, respectively, compared to robotic surgeons.
The aggregated findings suggest that robotic surgery is the most physically ergonomic surgical modality, followed by endoscopic surgery, while either open or laparoscopic surgeries could be ranked as the least ergonomic surgical modality. The results highlight the need for improved ergonomics even in robotic and endoscopic surgeries, as they are also associated with pain, discomfort, and neuromusculoskeletal symptoms. It is noteworthy that the response rate of 32% may have led to a skewed data set toward the surgeons who were facing high workload, body part pain/discomfort, or NMSDs. However, the results of this study include surgeons from three hospitals in three states and a distributed health system with both complex and routine cases. The findings of this study can help refine potential ergonomic interventions within preferred surgical modalities to enhance feasibility, applicability, and effectiveness.
References
Due to word limits the references will be provided per request.
Due to the increasing prevalence of work-related injuries reported by surgeons, there is a critical need for an improved ergonomic understanding and interventions in the operating room. One unanswered question is “do surgeons’ preferences for specific surgical modalities (e.g., open, laparoscopic, endoscopic, robot-assisted (robotic)) affect the incidence of NMSDs, pain, and physical discomfort? As each modality is associated with a different operative posture and orchestration of instrumentation, it warrants further analysis to determine if any of these surgical modalities are ergonomically protective or harmful for surgeons. This study sought to evaluate and compare surgeons’ wellness among four surgical modalities (endoscopic, laparoscopic, open, and robot-assisted). The study focused on thoracic and abdominopelvic surgeons due to the variety of surgical modalities they frequently utilize in their surgical practice.
This study was approved by the Institutional Review Board (IRB) of an academic hospital. The inclusion criteria covered all urologic, gynecologic, thoracic, and general (including breast, colorectal, hepato-pancreato-biliary, and bariatric) surgeons across all geographically distinct parts of this academic hospital system in the United States. An electronic survey using Qualtrics (Qualtrics, Provo, UT) was sent to the surgeons. The survey consisted of questions regarding demographics, anthropometrics, surgeons’ practice time per surgical modality, physical and mental demand (from 0=Not demanding to 10=Extremely demanding, modified from Surgery Task Load Index (SURG-TLX) (Wilson et al., 2011)), neuromusculoskeletal symptoms including body part discomfort/pain (modified from standardized Nordic musculoskeletal questionnaires NMSQ (Kuorinka et al., 1987)), NMSDs, burnout and job satisfaction.
The effects of modality on dependent variables that were recorded per surgical modality were evaluated using either the non-parametric Kruskal-Wallis test and post-hoc non-parametric Wilcoxon Signed-Rank test (pairwise comparisons) or a logistic regression and Wald-based pairwise comparisons (dependent on the type of the data). The effects of surgical modality on dependent variables that were not recorded per surgical modality were evaluated after each surgeon was allocated to a dominant surgical modality. The threshold for defining a dominant modality was as follows: 1) the difference in the percentage of the procedural time a surgeon spent performing different surgical modalities were calculated, 2. If there was a surgical modality which its difference from the other three modalities was “at least 10% or higher”, the surgeon was allocated to that surgical modality. Then, similar statistical methods were performed. For all statistical analyses in this study, a significance level of 0.05 was considered.
The electronic survey was sent to 245 thoracic and abdominopelvic surgeons; 79 surgeons completed the survey (response rate 32.2%), including 19 urologic, 22 gynecologic, 3 thoracic, and 35 general surgeons. The average (standard deviation (SD)) of the 79 respondent surgeons’ anthropometrics was age 46.6 (9.3) years, weight 77.7 (14.6) kg, and height 174.1 (8.9) cm. Thirty-one surgeons (39%) were female surgeons. Of the 79 respondents, 65 surgeons (82.2%) had a dominant surgical modality: 10 endoscopic, 15 laparoscopic, 26 open, and 14 robotic surgeons.
All surgeons were asked if they ever had or currently have neuromusculoskeletal pain. Fifty-nine percent of the 79 surgeons (regardless of modality) and 62% of the 65 surgeons with a dominant modality answered “yes” to this question. The results revealed that this problem was less prevalent among robotic surgeons (21%) relative to surgeons with other dominant surgical modalities (69%-80%) (all p < 0.01). No significant effect of surgical modality was found for the response to a question asking, “Do you feel that any physical discomfort or pain you experience will influence your ability to perform surgical procedures in the future?” and 35 out of all 79 surgeons (44%), regardless of modality, responded “Yes” (3 surgeons did not wish to answer to this question).
Physical demand was the highest for open surgery (6.25 (±2.24)) and the lowest for endoscopic (3.68 (±2.19)) and robotic (3.78 (±1.78)) surgeries (all p<0.05). Open (5.43(±2.01)) and robotic (5.23(±1.79)) surgeries required the highest levels of mental workload, followed by laparoscopic (4.7 (±1.99)) and endoscopic (3.0 (±1.77)) surgeries, respectively (all comparisons of modalities were p < 0.05 other than when robotic and laparoscopic surgeries were compared).
Physical discomfort/pain after a day of surgical procedure in open surgeries (4.58 (±2.46)) was higher than endoscopic (2.65 (±1.92)), laparoscopic (3.7 (±2.37)), and robotic (2.88 (±1.71)) surgeries (all p < 0.05). The results of the body part discomfort/pain questions revealed that discomfort/pain (immediately after surgery) was lower in the shoulder for robotic surgeons compared to laparoscopic (p = 0.0174) and open (p = 0.0377) surgeons, but only in the left fingers for robotic surgeons compared to the endoscopic surgeon (p = 0.0109). The prevalence of NMSD was significantly lower in robotic surgeons (7%) compared to the other surgical modalities (between 60% - 67%) (all p < 0.05). Overall, 39 out of the 65 surgeons (60%) used at least one general intervention or strategy (e.g., over-the-counter medicine, changing position) to minimize their operative discomfort or pain. This included 80% of endoscopic, 73% of laparoscopic, 65% of open, and 21% of robotic surgeons. 13 out of 65 surgeons (20%) had sought at least one method of medical help (e.g., injections, physiotherapy) to minimize their work-related discomfort or pain (10% of endoscopic, 27% of laparoscopic, 27% of open, and 7% of robotic surgeons).
Seven questions recorded the surgeons’ job-related feelings on a 7-level scale, and the responses were simplified so that the first three levels (“Never,” “A few times a year or less,” “Once a month or less”) were grouped as “less frequent” and the last four levels (“A few times a month,” “Once a week,” “A few times a week,” and “Every day”) were grouped as “more frequent.” The nominal logistic regression revealed that surgical modality was significantly affected if surgeons felt burned out from their work (p = 0.0223), where laparoscopic and open surgeons’ responses grouped as “more frequent” to this question were higher compared to robotic surgeons; the odds ratios were 5.50 (95% CI- 1.06-28.42) for laparoscopic and 6.93 (95% CI- 1.53-31.38) for open surgeons, respectively, compared to robotic surgeons.
The aggregated findings suggest that robotic surgery is the most physically ergonomic surgical modality, followed by endoscopic surgery, while either open or laparoscopic surgeries could be ranked as the least ergonomic surgical modality. The results highlight the need for improved ergonomics even in robotic and endoscopic surgeries, as they are also associated with pain, discomfort, and neuromusculoskeletal symptoms. It is noteworthy that the response rate of 32% may have led to a skewed data set toward the surgeons who were facing high workload, body part pain/discomfort, or NMSDs. However, the results of this study include surgeons from three hospitals in three states and a distributed health system with both complex and routine cases. The findings of this study can help refine potential ergonomic interventions within preferred surgical modalities to enhance feasibility, applicability, and effectiveness.
References
Due to word limits the references will be provided per request.
Event Type
Oral Presentations
TimeTuesday, March 268:30am - 8:50am CDT
LocationSalon A-1
Hospital Environments