You might have heard the phrase ‘everyone’s replaceable.’ That might be true for a lot of positions, but if you’re an eye care provider, it’s not. As a physician you’re not just a part of the practice—you are the practice. If you miss clinic or surgery days because of musculoskeletal injuries, the whole practice suffers scheduling and revenue setbacks. To keep your practice in tip-top shape you’ve got to keep your body in tip-top shape.
You may not realize it, but the activities you perform day in and day out cause wear and tear on your body: for eye care providers, the neck, back, shoulders, and wrists are areas of particular concern. Left unchecked over the years, this wear and tear can eventually lead to injury, according to Jeffrey L. Marx, who spoke to ophthalmologists about ergonomics at AAO 2017.
Some of the biggest factors affecting eye care providers, according to Marx, are poor postures, repetitive motions, and staying in an awkward position—say, head bent forward—for long durations. These factors combined can result in problems like musculoskeletal disorders (MSDs), cumulative trauma disorders (CTDs), and repetitive strain injuries (RSIs). The result is pain and discomfort that affects your mood, your productivity, and your bedside manner. Your overall quality of life will suffer, and even your leisure activities could be curtailed.
“We need to heighten awareness and the benefits of prevention before people will buy into a prevention plan.”—Scott Olitsky, MD
The 3 P’s of Prevention
Luckily, a few small adjustments now can go a long way towards preventing problems later. And prevention strategies are the key to healing and avoiding wear and tear on the body’s soft tissues that can lead to an injury. After all, it’s all too easy to ignore inconveniences like a sore neck or back until they turn into bigger problems—like missed work days and lost income. There are three main ideas to keep in mind throughout the day, according to Scott E. Olitsky, MD, who also spoke about ergonomics at AAO 2017: your posture, positioning of yourself and the patient, and taking a few minutes to practice periodic stretching.
Ergonomics In the Clinic
- Pay attention to your clinical setup. In many practices, treatment rooms are identical. That means you’re stressing one side of the body Set up rooms so that you’re not always leaning the same way. It may feel awkward at first to use the rooms that make you lean the other way, but you can train yourself to vary positions.
- You’ll be performing many clinic activities seated on a stool—unsupported sitting. Wehking likes models where the seat tilts forward and back, but whatever style you choose, remember that “posture starts at the pelvis.”
- Take a few moments to position yourself in front of the patient. Try to get your exam stool wheels underneath the patient’s footrest so that you don’t have to reach forward during the examination. Raise the footrest if necessary.
Tip: When performing retinoscopy, try switching hands regularly to ease the burden on your dominant side.
The Ergonomics of Medical Equipment
Many pieces of equipment you use regularly weren’t created with ergonomics in mind. “Indirect ophthalmoscopy [is] and ergonomic jungle” due to the constant bending and leaning, Dr. Marx jokes. And forcing your body into awkward positions to accommodate equipment can eventually cause neck pain, numbness in the hands and arms, and even cervical problems. Until manufacturers start designing tools with ergonomics in mind, here are a few tips for coping:
- Shorten or narrow your slit lamp table to increase your reach and bring the slit lamp closer to you. That way, you can avoid leaning forward and extending your neck. Sitting up straight can also help you keep your wrist in a neutral position (instead of bent) when using the controls.
- Many physicians rest their elbow on the slit lamp table to steady their hand. Over time, the constant pressure on the elbow—which isn’t meant to be weight-bearing—can cause numbness and tingling. That’s nerve damage. Instead, use a gel rest to support your elbow, advisees Marx.
Ophthalmologists administer millions of injections each year. That makes repetitive motion injuries a top concern.
Don’t put sharps disposals container underneath the sink. You will need to bend awkwardly to throw away sharps. Put the container on the wall for easier reach instead.
The eyes are already two of the human body’s smallest structures, and for pediatric ophthalmologists, they’re even smaller. Olitsky gives these ergonomic tips for treating your smallest patients:
- Failing to properly position the patient is one of the biggest problems. Taking just a few extra seconds to position yourself and the patient properly can greatly reduce the stress on your neck, back, and shoulders.
- For children, who tend to sit back far from the seat edge, consider using a foam wedge behind their backs to bring the forward and decrease the distance you must reach.
- Tilt chairs back so that you don’t have to duck underneath the patient.
- Raising small patients to the right height will help keep your hand, wrist, arm and elbow in alignment.
- Many physicians were trained to sit at head of patient. Instead, try sitting on the side, or switching positions occasionally.
Ergonomics in the Operating Room
The main issue in the OR is posture. Ophthalmology surgeries don’t often require much movement, so surgeons are stuck in the same position for long periods of time. For many surgeons, that means sitting, leaning forward, with the neck extended and the head bent—and that’s no good. Your head likely weighs somewhere between 10 and 12 pounds. As you tilt your head forward, the muscles, tendons, and ligaments that support your head must work increasingly harder the more the tilt. This creates wear and tear on the entire neck structure, resulting in neck and upper back pain, and could even lead to disc problems and spinal degeneration.
Tip: For your surgical chair, upper extremity support is important, says Jeremy Wehking PT, OCS, FAAOMPT, PRC, who also spoke at AAO. For some, turning a backed chair around so you have some lean in support works very well, he notes.
Tip: Consider standing. Dr. Glaucomflecken, a popular med-Twitter personality, recently joked that he chose ophthalmology as a specialty so he could operate sitting down. That’s good for a laugh, but unfortunately, it’s not as great as it sounds. Actually, standing in the OR is better for your body in the long run. Standing puts less weight on your lumbar spine, allows surgeons and staff of varying heights to all maintain proper posture, and it allows you to move more frequently and easily, notes Olitsky. Not only that, you burn approximately 800 calories more per day when you are standing as opposed to sitting.
And don’t forget to periodically pause and stretch to get blood moving to muscles. According to a new study by Adrian Park, MD, chair of the Department of Surgery at Anne Arundel Medical Center, surgeons who periodically pause for 90 seconds to perform a series of stretches throughout an operation report less work-related discomfort and an improvement in physical performance and mental focus. Granted, you may not want to interrupt a 10-minute cataract case with a minute and a half of stretching, but stretching afterwards and between cases is a smart idea.
- If your equipment has pedals of differing heights, put a towel under the lower ones so they are all the same height, recommends Marx.
- Make sure you’re using the right binocular for your size and shape. One size does not fit all.
- Don’t hunch. Adjust equipment to the proper level and working distance.
- This will vary depending on preference, but some surgeons opt for “heads-up” surgery, viewing on a screen (with 3D display) instead of directly through the microscope.
Eyewear for Providers
You don’t want your patients buying cheap glasses and lenses online, so why would you? Get fitted for a good pair of loupes, and don’t buy $16.99 loupes on eBay, Olitsky quips.
Choose a loupe that has a good declination angle for you, he recommends. You can find and measure this angle by drawing a line from where the temple piece of a spectacle rests on your ear to the bridge of your nose. This is the optimal angle to position your eyes when in “balanced operating position,” notes Olitsky.
Your working distance needs to be individualized, Olitsky emphasizes. He often sees physicians, and especially residents, whose working distances are too short. When adjusting your working distance, you’ll need to also adjust the magnification of your loupes.
8 Steps to Find Your Balanced Operating Position (BOP)
Finding and maintaining your BOP will reduce the risk of musculoskeletal pain. Olitsky explains how:
- Sit in chair without using backrest
- Adjust chair for comfort
- Arms and hands at sides
- Close eyes
- Adjust head for comfort
- Bring arms to position for fine motor work
- Open eyes and look at hands
- Adjust eyes/head as needed but maintain comfort
Ergonomics In the Office
If you had your way, you’d be spending far less time on paperwork and the computer. Unfortunately, that’s not the reality for today’s physicians. But seated deskwork presents its own ergonomic challenges:
- Check your computer habits. Good computer posture means:
- Sitting as far back as possible in the chair
- Feet flat on the floor with knees level with (or just below) your hips.
- Adjust armrest to a height where your shoulders are at rest.
- If you work on a laptop, get a stand. The top of the screen should be just above your seated eye level. Or, consider standing desks for you and your staff.
- Don’t cradle the phone. If you’re on the phone a lot, consider a headset.
- Stretch throughout your day or whenever possible. For example, a hip flexor stretch can help alleviate pain in the lower back hips caused by prolonged sitting.
“Our staff mirror the same things we do. Mirror good ergonomic habits for your staff.”—Jeffrey L. Marx, MD
Ergonomics At Home
The “Three P’s” don’t stop just because your workday is over. Monitoring your posture and position during your off-duty activities is just as important in terms of keeping your body’s structures in healthy, working condition.
- Practice proper sleep posture. Make sure your pillow is not too high or too low. Your neck should be in neutral alignment. “Sleeping on your stomach is likely the cause for your still and painful neck,” says Olitsky. A back or side position is better.
- When working—or playing— on smartphones, the head is often tilted forward and down. This can lead to “text-neck,” or anterior head syndrome. Try holding the phone at eye level. It may look odd to others, but your body will thank you. Better yet, try limiting non-essential smart phone use as much as possible during non-work hours.
- Practice corrective exercises. Corrective exercises do two things: they “get you into a good position and get you strong enough to stay that way,” Wehking explains. “We don’t want to put fitness on top of dysfunction,” he adds. Corrective exercises can help alleviate pain caused by musculoskeletal imbalances.