IBD Drive Time: Patrick Young, MD, on Ergonomics and Endoscopy

Dr Patrick Young provides guidance in how to prevent injury and discomfort when performing endoscopy in this episode of IBD Drive Time with host Dr Raymond Cross.

Patrick Young, MD, is director of the Digestive Disease Division at the Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, Maryland. Raymond Cross, MD, is a professor of medicine and director of the IBD Program at the University of Maryland School of Medicine in Baltimore.

TRANSCRIPT:

Dr. Raymond Cross:

Welcome everyone to IBD Drive Time. I'm Raymond Cross from the University of Maryland School of Medicine, and I'm really happy to have a non-IBD faculty member here, my friend Patrick Young, from the Uniformed Service University and Walter Reed National Military Medical Center. He’s going to talk to us about ergonomics of endoscopy. Pat, welcome to IBD Drive Time. You're the first non-IBD person on the podcast.

Dr. Patrick Young:

Thanks, Ray. And you know, my friends told me I was not smart enough to be on a podcast like this. So I just had to kind of get a back door way in. So that's all good. I'm glad I made it.

Dr. Cross:

Great. So IBD faculty do plenty of endoscopy. So this is a really pertinent topic for them, and maybe just starting off with how common are injuries related to the performance of endoscopy amongst gastroenterologists, and maybe focusing more on luminal stuff, not the advanced procedures per se.

Dr Young:

Right. Unfortunately, they're incredibly common. So even if you are what I would call a bread-and-butter gastroenterologist—you know, you're doing EGDs and colonoscopies—there's a rate of around 58% of folks. So the majority of people will get some sort of what we call endoscopy- related injury Or ERI —an acronym we all use—during their career. You know, I'm a therapeutic guy. And so for us, it's 3 quarters of us, 75% will do that. It is not evenly distributed between men and women. And so, as you know, we've got more and more women, which is great in the field of gastroenterology. But they're more at risk for getting an ERI, an endoscopically related injury. And so 73% of them will be injured. Even if they're just general gastros, or not doing any ERCP or other things that involve the use of elevators or prolonged procedures. And so it's a big problem. And with the looming, or I would even say current, in some regions, shortage of gastroenterologists, we need all hands on deck. Losing time to injuries and things like that is not only going to cost us, but it's going to cost our patients. There's won't be enough of us to do the things that need to get done.

Dr. Cross:

Well, I knew it was common, but almost 60% on average, I didn't realize it was that high—that's staggering. We're almost uninsurable.

Dr Young:

Well, I mean, it's interesting. You bring up insurance. I mean, I think that having disability insurance is something that I mention in every talk, so they will insure you. There's a cost with that. And you know I would make sure that when you get it, that it is type-specific, meaning that it says if I can't work as a gastroenterologist, then I will get this insurance money, not just if I can't work. And there's 6 companies that do that, you can google those things. But make sure that “own occupation specific” is the language that you need to have in the in the contract.

Dr. Cross:

So I want to talk a little bit about women. And so you know clearly, it's really nice to see that we have more and more women in gastroenterology and hepatology, and you know I've often thought about this as I'm scoping with trainees. You know I'm a bigger person. But like looking at their hand size compared to mine, and looking at the dials on the scope, these scopes weren't ergonomically designed for women and correct me if I'm wrong, but it seems like maybe there needs to be some more thoughtful design and endoscopes that tailor scopes to people that have smaller hands, and some men are smaller, too, as well. So is that is that valid?

Dr Young:

That's completely valid. And so you know, one of the things that we talk about is this one size fits none model, right? And so, you know, it was designed right when it was mostly men doing this. And it's not just hand size. So if you, if you look at the surgical literature and they were ahead of us in the ergonomics world, even women who had the same hand size as a man were more likely to get injured. So if you're a man with a 7 1/2 glove and a woman with a 7 1/2 glove, the woman is the person to bet on for getting an ergonomic-related injury, and if you look at just across the board, a 20-year-old woman has the grip strength of a 70-year-old man. So there's just inherent differences in musculature and tendon strength and resilience.

Now some of those things can be trained, and we can talk about that later on, about how to increase your resilience, make yourself a hardier endoscopist. But I think you're right in the long term is that we need to have better scope designs. We actually sat down—I was part of a task force through the ACG—and we got together with the major scope manufacturers, and we had this conversation in October and talked about how we might be able to redesign some of these scopes, and I think the bottom line is it's going to need to be iterative. So like wholesale changing the way we do it, you know, going and making it look more like a PS5 or something is probably not going to be acceptable to most gastroenterologists. But all my fellows would probably love it, you know. So some iterative change. The scopes get lighter, the dials get smaller. You make extenders so that people can reach it better. All those sorts of things, I think, are on the table for ways to improve those.

Dr Cross:

If they make it like a PS5, we're going to be obsolete, Pat.

Dr Young:

You joke about that. But I honestly think that's part of the resistance to change because there are people who make those systems now that are, you know, FDA approved and available for purchase. But people don't want to do it, and I mean, I'll just say the obvious, like as a guy who's in his 50s, who's been doing this a long time, it would be kind of embarrassing if a 30-year-old who grew up, you know, playing Fortnite, and you know, whatever other games, was already better than I am, because he knows how to work the controllers better. Right? So there is some of that out there.

Dr. Cross:

I don’t want my sons to be able to scope better than me with no training. That would be embarrassing, I agree.

Dr Young:

Exactly

Dr Cross:

So what are the— just intuitively it seems like hand, wrist, maybe neck. What really are the common injuries  that we experience? 

Dr Young:

Yeah, so your right hand and finger are number one, but then actually after that, it's lower back and then upper back and neck. So kind of the posterior chain. There, you know, we end up sometimes in odd positions. I mean, you've like me. You've trained fellows for years, and and one of the things that we do is we sort of personify ourselves as a scope. So you know, you want to look around a corner, so what do you do? You turn your head and you try to look around the corner. And you know, doing that over time is going to set you up for injury, right? Which is why I think the neck and the back end up getting injured so much. The hands are obvious. You end up sort of in the maximum range of your thumb extension, or you end up having to hold torque for a long time and grip it with that right hand. And that's that's how we get injured.

Dr. Cross:

Yeah, I don't typically lay hands on trainees. But this is the one situation where I do when they're doing that, when they're putting themselves in awkward positions. You look at the scope, and it's bound up so tight, and I'm like, listen, I'll touch their arm, like, relax your hands like it's not only that the scope is not going to be responsive. But also you're putting an incredible amount of pressure on your joints when you're in those awkward positions, and sometimes you can't really recognize it until someone points it out to you.

Dr Young:

No, I think I think that's right. The way that I described that to them is you really want to return to neutrality as fast as you can. Just be as Swiss as possible, right? Just get yourself in a nice neutral body position, natural curves of the neck and back, and actually, like you said, you end up just being more effective long term as an endoscopic way, not only just reducing injury, but just the fatigue factor. You know how hard it is to even make good decisions when you start to get tired. Right? So all those things kind of factor in, I think.

Dr Cross:

For me, the most recent thing that's made me a better endoscopist is recognizing that tactile stimulus on the scope and feeling the tension on the scope. And like I'm going to steal that from you, getting neutral as quickly as possible, because the scope won't do what you want it to do. It doesn't respond properly. And then you're frustrated, and it increases the amount of time. And it's a really good, simple tip.

If you could just summarize three tips? What are the 3, maybe most important, cost -effective strategies or tips that you can employ to prevent injuries? There might be, I'm sure there's more than that.

Dr Young:

Yeah. But I mean, cost effective is important. Right? Cause I'm so I'm going to talk about things that are free or nearly free. So one of them is what we just described. Right? So, having a good neutral body position, understanding what that is, you know, putting the equipment in the right position. So you know, you use electrocautery or you use something else that requires the use of pedals. And maybe the tech just kind of puts them off to the side of your feet instead of in front of you. So now you're having to kind of turn your body or turn your head and neck, and you put yourself in that awkward position. So just making sure everything is lined up, the towers directly behind you, the monitor is directly in front of you and at the right height. You're in a neutral body position, I mean, that's all free, right? And that's where just kind of checking on those things is beneficial.

And then in between procedures, taking micro-breaks and stretching a little bit, you know. And you're not going to do you know a full body yoga session between every case, But maybe, you know, you do a case, and you should kind of stretch your neck a little bit, you know. You look up for 10 seconds, and you look down for 10 seconds. Look to the left, look to the right for 10 seconds each, and now you've done a neck stretch. And then maybe, after the next case, you stretch out your forearms a little bit. I mean, you know, you figure out what works for you but just making that the mindset.

And then the last one, honestly, is getting antifatigue mats for your unit. What those things do is they induce postural instability. So you can't really stand still perfectly while you're doing that. You're always sort of shifting from one foot to the other, and bearing weight a little bit different makes you more balanced, honestly, to do that. Most places will allow you. I know some people have told me that infection control feels like you can't clean those adequately, although there's no data to suggest that, and in that case I would just say, having good footwear, you know, that does basically the same thing, having, like either pads in your shoes, or these really padded running shoes like you see nowadays, are not free, but fairly economical in the grand scheme of things.

Dr. Cross:

Yeah, we don't have the mats at university, but at the ambulatory surgical center±at one of the ambulatory centers I scope at—that they have them, and I think they make a huge difference. I mean, I'm an old football player, so sometimes my feet and knees can ache a bit, and I don't really have that when I'm using the anti-fatigue mats. It really makes a big difference.

I don't think you coined this term but I heard this somewhere: the concept, you know, we do the timeouts before procedures—which in cases where I've had patients for 15 years, I frankly find that silly—but you know we should be doing like an ergonomic timeout. Like as you said, checking where the screen level is, making sure your water flush, your cautery pedal if it's pulled out ahead of time, that the level of the bed all of that is exactly where you want it to be before you start.

Dr Young:

Yeah, I agree with that 100%, that having a checklist that you do briefly, really at the beginning of every endoscopic session. So it's not between every case, right? We just make sure when you start off that you've got the monitor that's directed in front of you and then 15 to 20 degrees below the horizon is where your eyes should be looking to keep the natural neck curves. You want the bed height to be adjusted so that your forearms are either parallel to the floor or slightly below that. You want the pedals in front of you.

And then remember, there's other people in the room who could have an injury. So you know all these cords and stuff that we have, making sure that those things are contained on the floor. You don't have trip hazards. That's actually the number one way that nurses and techs get injured, as you know, tripping and falling in the endo room, and then if you're somebody who uses lead, having super-light lead, and then ideally, 2-piece lead so that you're not bearing it all on your shoulders. And then again doing those micro-breaks and stretches and having that neutral body position. Those are all part of a good checklist.

Dr. Cross:

Very reasonable things to do, and probably more important in the patient timeout in some cases. I was on a guideline committee for endoscopic balloon dilation, and there was a minor argument about what scopes we should be using for stricture dilation. And they were trying to force the pediatric colonoscope, and I'm like, wait a minute. We shouldn't tell the gastroenterologist what scopes to use, and I personally like the adult colonoscope and a couple of my friends on the call said, you know, you're going to have more injuries using the adult scope. But I find that I can't really… I find that that pediatric scope is way too loopy for me, and I don't need it to get around turns. Am I increasing my chance of injury using an adult scope?

Dr Young:

Well, if you are, we both are because I use adult scopes for almost everybody. I'll tell you to start with, there's no evidence that that is the case. And you know, I get referred a lot of difficult colonoscopies. Maybe somebody else has failed and stuff like that. And I what I tell my fellows, is MAC, water, and a good adult colonoscope is what makes me look good. Right? It allows me to complete the case because they're just less loopy, and from an ergonomics perspective, you know, Oxo makes their good grip handles bigger for a reason.

Right? I just it takes less force to kind of grip. That thing, the smaller it is, the harder it is to hold and then induce force on it. Right? That's just physics. So I like a little bit wider scope for me. That's my feeling.

So the short answer is, no, I don't think that you are increasing your risk of injury. It's not that I never use a pediatric scope in certain patients, but for most patients I don't think for me it's the right answer.

Dr. Cross:

I feel much better now.

And then, you know, when you start doing procedures at an ambulatory surgical center, the efficiency, and the volume you can do is really stunning. And as we're talking, I'm thinking about, you know, typically I think they want to shoot for a target of— I think a reasonable place is shooting for a target of about 14 to 15 procedures, and that can include upper endoscopies as well, in a full 8-hour session. Is there a threshold as far as number of procedures, where, if you start to routinely get above that number?

Dr Young:

Yes, total volume is associated with injury. And, you know, look, I understand that the practice of GI isn't all about ergonomics and avoiding injury, right? So in an ideal world, you would not scope a whole day. You would scope maybe half a day, see clinic half a day, or do administrative tasks, whatever else needed to be done.

But I understand that, you know, not everybody scopes where they see clinic and sometimes it's just inconvenient, or there's other reasons why you might need to do that, which is why these other practices are helpful. As well as just making yourself more resilient. So you know, I spent a long time in the military and sometimes some of the people who are out there doing way more military things than I did as a physician, they have to go through physically difficult things.

Sometimes we have to go through physically difficult things. And so you optimize them as best you can. And then you try to make yourself, I don't want to use the word hardened, but resilient and resistant to injury as best you can, so that even if you get an injury, you're going to recover faster from it, right? So that's the thing.

The other thing I would add is that age is also a factor, so years performing endoscopy is also associated with injury. I'm sure you and I are kind of both, I don't say former athletes, I think of still a little bit of an athlete and you may be as well. But we don't bounce like we used to, right? Like you get an injury that takes you longer to come back

Dr Cross:

It's funny you mentioned 20 because there's been twice in my career where I've gone over the 20 number and I definitely could feel it when I left the endoscopy suite— and not just physically, but mentally, it's a challenge to try to stay sharp doing that many procedures. So I think the administrators targeting that 14 to 16 is probably a reasonable number that balances ergonomics, patient safety, and efficiency, and finances. So I think it's a reasonable number. 

So outside of the endoscopy suite, what can gastroenterologists do to prevent injury? Should I be doing core exercises? Exercises a couple times a week, or is there anything just common sense or proven that will help us? 

Dr Young:

Yeah, I mean, I think it's mostly common sense. Honestly, I would say, there's not a lot of data looking at this specifically. And so we borrow a lot from other physical tasks. You know, people who are turning wrenches and screwdrivers; you know, torque and a colonoscope are not so different than turning a screwdriver. Right? I mean, it's the same physical forces. And so it's really a couple of things. You mentioned one of them, which is sort of the posterior chain and the core, you know, postural stability strengthening. So you know, any exercises that target that, planks or things like that. Yoga is actually really good. A lot of the positions are going to make you induce postural stability, and, you know, strengthen your core, make you maybe even a little bit more flexible and stable, which is going to be important. That balance, you know.

We do grip a lot, you know, sort of hand and the forearm injuries that people get. And so there's lots of different ways to do grip strengthening. You know, farmers carries are a good one. Any exercise where you're holding moderately heavy weights for a period of time. So dead lifts, or even just, you know, picking the bar up and holding it and maybe not doing the full deadlift is going to be beneficial, hanging off of a bar. All of those kind of things are, going to be helpful, you know. You don't need to be a Crossfit games athlete to make yourself more resilient.

And then I actually think, although there's not great data for this, that just learning how to be more mindful is beneficial. We talked about trainees, you know, just not being aware of what their bodies doing in space cause. They're so focused on what's going on on the screen. But I think that could happen to any of us, honestly, as we get so just being a little bit more mindful of what's happening to you physically is going to pay dividends down the road, I think.

Dr. Cross:

Yeah, I agree. Very, very common-sense stuff.

So before I go to the fun question. I just wanna remind our listeners that we are sponsored by the AIBD network. And we are on Apple podcast and Spotify. So please subscribe to IBD Drive Time so that you have this regularly in your queue of podcasts to listen to. And also there is a regional Advances in IBD coming up in Boston, April 5th and April 6th.  Importantly, registration is now free for attendees. So spread the word that we can attend this great conference for free and learn a lot about IBD.

So Pat, this is the fun question. Tell the audience something about yourself that they may not know maybe something even that I wouldn't know about you.

Dr Young:

I'm sure some members of your audience know this at this point, but you may not. I'm an avid musician. So you know, I've spent most of my life playing in rock bands, singing, playing bass, writing songs, doing that kind of stuff. I almost did it for a living.

And the first real piece of mentorship advice I got—one of those like just having dinner with another musician who was older than me, he seemed old at the time, hee was probably like 32 at the time when I was 17 out playing in clubs, and you know, on people's albums and stuff. And you know, I was thinking about making this a career. And the guy said, you know.

if you can't imagine doing anything else in your life, then you should absolutely go for it. Press into it. Do everything you can, he said. But if you can imagine another way, something else you could do for a career that would make you happy, you can always have music. You're always going to find guys who want to play. There's always going to be opportunities. You'll get 90% of the fun and like 0% of the headaches that come with trying to be a professional musician.

And honestly, as much as any other piece of advice, and I've gotten a lot of them over the years—that just made me pivot, and he's exactly right. So I'll continue to play with people. We've got a little band in ACG, you know, with some of the guys that I'm on the board with, and we get together whenever we can to jam and stuff like that. I play with some folks here. And it's just amazing fun and actually, it makes me maybe more attuned to ergonomics, because not only do I want to be able to scope, I want to be able to keep playing base, which also, you know I need my hands and wrist to do. So it's all good.

Dr Cross:

That's great, Pat. I was going to ask you what instrument— I thought it was guitar. And so I was correct. And I keep telling Rebecca that we need to get the Beacons on to do an IBD Drive Time special, have you guys play a few songs so hopefully. We'll have you back to do that.

Pat, this has been great. I learned a lot. I know our listeners learned a lot. And like, I said hopefully, we'll have you back with the Beacons to play a few songs on IBD Drive Time. Thanks again.

Dr Young:

Yeah, my pleasure, Ray. Thanks so much for having me; great seeing you again.