Female Surgical Ergonomics in Otolaryngology

Abstract

Objective:

To explore the surgical ergonomic challenges experienced by women in otolaryngology, identify specific equipment that is ergonomically challenging, and assess the impact of suboptimal ergonomics on female otolaryngologists.

Methods:

We performed a qualitative study using an interpretive framework rooted in grounded theory. We performed semi-structured qualitative interviews of 14 female otolaryngologists from 9 institutions at various stages in training and across subspecialties. Interviews were independently analyzed by thematic content analysis by two researchers and inter-rater reliability was assessed via Cohen’s kappa. Differing opinions were reconciled via discussion.

Results:

Participants noted difficulties with equipment including microscopes, chairs, step stools, and tables as well as difficulty using larger surgical instruments, preference for smaller instruments, frustration with lack of smaller instruments, and a desire for a larger spectrum of instrument sizes. Participants reported neck, hand and back pain associated with operating. Participants suggested modifications to the operative environment, including a wider variety of instrument sizes, adjustable instruments, and more focus and attention on ergonomic issues and the range of surgeon physiques. Participants felt that optimizing their operating room set-up was an additional burden on them, and that lack of inclusive instrumentation affected their sense of belonging. Participants emphasized positive stories of mentorship and empowerment from peers and superiors of all genders.

Conclusion:

Female otolaryngologists face unique ergonomic challenges. As the otolaryngology workforce becomes increasingly diverse, it is important to address the needs of a diverse set of physiques to avoid inadvertently disadvantaging certain individuals.

Lay Summary:

In this qualitative interview study, we found that female otolaryngologists struggled with larger instruments and equipment such as microscopes and chairs. Participants reported pain associated with operating, that ergonomics affected their self-perception as surgeons, and had multiple suggestions for improvement.

INTRODUCTION

In the past several decades, surgical ergonomics has received increased attention, in part due to high rates of musculoskeletal injuries reported by many surgeons.^1,2 Surgery is a historically male-dominated field, and the operating room environment and instrumentation have been designed to accommodate the average male surgeon, who differs significantly in stature, hand size, and strength from the average female.³ Several unique difficulties experienced by female surgeons have been reported, including increased difficulty with laparoscopic instruments, more muscular effort for their use, and using laparoscopic tools differently than they were designed.^4–6

Otolaryngology has specific ergonomic challenges, including the cumulative physical load from repetitive common procedures, frequently operating with one’s head bent forward or twisted, and frequent headlight and loupe usage.^7–14 A recent meta-analysis by Ryan et al (2022) found a 78% rate of work-related musculoskeletal injuries among otolaryngologists, similar to other surgical specialties.^1,7,15 Previous publications have noted a higher incidence of work-related musculoskeletal complaints among female otolaryngologists, but the cause of this has not been investigated.^10,11

In this study, we sought to investigate the surgical ergonomics of women in otolaryngology. Specifically, we aimed to explore the surgical ergonomic challenges experienced by women in otolaryngology, identify specific equipment and instruments that contribute to ergonomic difficulties, and assess the impact of suboptimal ergonomics on female otolaryngologists.

MATERIALS AND METHODS

Study Design

In this study, we used an interpretive framework rooted in grounded theory (see Figure 1 for definitions of key qualitative research terms)¹⁶ to understand the surgical ergonomic experience of female otolaryngologists and identify areas for improvement. Semi-structured interviews, were performed. The study was approved by the Weill Cornell Medical College Institutional Review Board.

Figure 1.

Definitions of Key Qualitative Research Terms

Study Sample

Participants were recruited via convenience and deviant case sampling (Figure 1). Interviews were conducted with 14 female otolaryngologists, with sample size determined by thematic saturation (Figure 1) and adequate subspecialty representation.

Data Collection

Participants were provided with open-ended questions with minimal response by the interviewer. All interviews were performed by one research team member (EM). Interviews were conducted and recorded via Zoom (Zoom Video Communications, San Jose, CA, USA). Surgical background and physical data were collected from participants. Interview questions explored 4 categories: technical surgical challenges, physical pain, teaching and being taught, and sense of belonging. The interview protocol was tested during a mock interview and refined based on interviewer and interviewee feedback. Interviews were recorded and transcribed verbatim. Interviews were conducted March-May 2022. The interviews lasted 17–35 minutes in duration, depending on participant response.

Data Analysis

NVivo (QSR International, Melbourne, AUS) software (version 12) was used to code interview transcriptions. The first 3 interviews performed were inductively coded via thematic content analysis (Figure 1) by 3 authors (EM, HB, LH) with independent generation of codebooks by each author. Codebooks were reconciled via consensus discussion with the generation of a finalized codebook that was used to deductively code all 14 interviews. Coding was performed independently by two researchers (EM, LH) and coding differences were reconciled by consensus discussion. Thematic saturation was reached. Study authors included a medical student with limited knowledge of the surgical environment, a female otolaryngology resident, a female otolaryngology fellow, and a female attending otolaryngologist, all of whom are of a variety of physical sizes. All participants were personally known by at least one researcher. Content checking was performed by sharing the study results with participants, who all supported the portrayal of the study findings.

RESULTS

Prior to consensus discussion, inter-rater reliability between the two coders as measured by Cohen’s kappa was 0.68 and percent agreement was 97%, corresponding to substantial agreement.¹⁷

Participant Characteristics

Fourteen participants were interviewed, including 2 residents, 1 fellow, and 11 attendings. 1–2 attendings from each subspecialty (rhinology, facial plastics, head and neck, neuro-otology, pediatrics, and laryngology) were included. Participants were affiliated with 9 different institutions and included private practice as well as academic surgeons. Participants had a mean 9 years of surgical practice including training (range 2–18 years) and were in the operating room for a mean of 16.5 hours/week (range: 4–30). Mean glove size was 6 (range: 5.5–6.5) and mean height was 5’2” (range: 4’11”−5’8”). All participants were right-hand dominant.

Instrumentation

Exemplar quotes regarding instrumentation are given in Table 1. Participants expressed difficulty with a variety of surgical instruments, including clamps and needle drivers, suction bovies, drills, ligasures, microdebriders, retractors, and rigid endoscopes (Q1-Q7). Many participants felt they were unable to use instruments as they were designed and had to adjust their grip or use of instruments to make them work for their hand size, such as “put[ting] my fingers in the holes of instruments” (Q8-Q10). Multiple participants expressed a preference for smaller versions of instruments, and frustration when only larger instruments were available, saying that it felt “like a lot of the instruments are made for men” (Q11-Q17). Instrumentation in otology was commonly described as much easier due to the smaller size of the instruments, excluding some drills (Q18-Q20).

Table 1.

Exemplar Quotations: Instruments

Theme	Exemplar Quotations
Specific Instruments	Q1: “The otologic drills, they’re really designed for a man’s hand… they’re heavy and their diameter is kind of wide” Q2: “There are instruments that are totally not designed from my size hand… like the [suction] bovie… the blue button is farther back from my hand in terms of the grip.” Q3: “There are some really tight, squeaky endoscopic instruments that and also some rongeurs that are really big, like they have really big handles. So sometimes I’ll need like two hands for those.” Q4: “A smaller automatic clip applier would be more helpful.” Q5: “The microdebrider is designed for a larger hand. The laryngeal instruments are designed for a longer torso.” Q6: “For small hands… the Richardson Retractors are harder to use compared to like an Army Navy or hooks.” Q7: “[With the] stryker endoscopy set, the camera head tends to be a little bit heavier on my hands.”
Adjusting Grip or Use	Q8: “When I’m doing sinus surgery, I’ve been shown to hold instruments one way, but I’ve found that holding them that way is a little bit too difficult.” Q9: “Have I figured out the strategies that enable me to do the surgery? Yes, but it probably looks a little different with certain surgeries than other people.” Q10: “I generally don’t put my fingers in the holes of instruments.”
Smaller Versions of Instruments	Q11: “I would say things like the small needle drivers I definitely prefer.” Q12: “For things like dissectors… I generally do better with the shorter instruments.” Q13: “If the laryngeal instruments were a little bit shorter, that would be very helpful.” Q14: “When I sew, I always ask for the small needle driver… that’s been very helpful to me. Some sets don’t have that, but most do because the larger ones are just much larger than my hand.” Q15: “Part of why I gravitated to facial plastics is the instruments are much smaller and I actually feel like they’re all female sized. [My OR staff] know not to hand me big manly instruments, I don’t like the way they feel in my hand, they don’t fit right.” Q16: “A lot of times will use a pediatric tray instead of a head and neck tray.” Q17: “It just seems like a lot of the instruments are made for men and like, I get really frustrated sometimes when I get handed an instrument and there’s not a small size.”
Female Ergonomic Advantage	Q18: “Our hands tend to be a little bit smaller than a man’s, especially for otologic surgery, you just have a very finite space between a microscope and the patient’s ear so you can kind of maneuver a little bit better… so in some ways, ergonomics kind of work for females. For otologic cases.” Q19: “I think that people who are taller, they do have issues in terms of fitting their bodies under the table and getting the angles. And I think that I actually have more at my disposal.” Q20: “I think as someone small, it’s probably easier to squeeze between machines and around corners, reach under the bed to reach a knob.”

Quotations lightly edited for ease of reading (removing “like,” “um,” “you know,” and similar phrases.)

Equipment

Exemplar quotes regarding equipment use are given in Table 2. Chairs, microscopes, operating room beds, step stools, overhead lights, and equipment pedals and foot controls were cited by participants as particularly challenging to use. Participants reported that chairs used in both otology and laryngology, particularly newer models, did not go down far enough for them to put their feet on the floor while operating (Q21-Q23). Participants also reported problems with microscopes, particularly when using the longer focal length required for laryngology cases and feeling like their arms were “fully and utterly outstretched” while operating, reducing their stability and precision. This was worse when using microscopes with a longer distance from the eyepiece to the lens (Q24-Q26). Participants reported beds “aren’t even designed to go down” to a level appropriate for their height (Q27-Q28), frequently requiring a step stool, frustration with always having to go “hunting for a step stool”, and having to use two step stools stacked on top of each other due to unavailability of a tall enough step stool (Q29-Q31). Participants also reported that reaching overhead lights was “so hard” (Q32, Q33).

Table 2.

Exemplar Quotations: Equipment

Theme	Exemplar Quotations
Chairs	Q21: “I would prefer a chair that can descend low enough so that my feet can sit squarely on the ground when I sit squarely in the chair.” Q22: “All of the replacement brands, they don’t descend it low as a woman needs it to. And whoever’s looking into purchasing can’t find a chair that descends as low as the old ones do.” Q23: “I don’t weigh enough when I sit on it to lower the chair. I have to have my OR staff push on my chair.”
Microscopes	Q24: “Particularly with microscopic stuff... I’m fully and utterly, completely outstretched.” Q25: “Your arms aren’t long enough to reach with that working distance from the microscope. It’s just not optimal and… it’s less precise and you’re not as stabilized.” Q26:“When I’m doing microlaryngeal work… I have to sit further back relative to somebody who would have longer arms. They’d be able to bend their arms, rest them on an arm rest and be a little bit closer. But it’s difficult for me… because my arms aren’t as long, it feels like they’re kind of hanging sometimes, it’s harder to stabilize”
Beds and Tables	Q27: “Table height can be an issue for me. It’s definitely better when we have beds that go down all the way.” Q28: “There are some OR tables that aren’t even designed to go down to a level that would be comfortable for someone my height without a step.”
Step Stools	Q29: “I’m shorter, so I find myself on step stools a lot. Sometimes I’m on two.” Q30: “I almost always… have to go hunting for a step stool… even as an attending… Do I belong here if I have to, like, go and like, look for it every single time?” Q31: “I almost fell off a stool one time because I was operating with a really tall resident and I had to use two step stools.”
Overhead Lights	Q32: “I think the overhead lights are so hard for someone who is not really tall and has a very large wingspan… someone always has to help me.” Q33: “Everything seems like the wrong size, like the handles for the light, the height of everything. I don’t know what the solution is, but it does feel like, I mean, there is an awareness that we’re kind of in a world that we don’t belong in.”
Foot Controls	Q34: “Constantly needing the pedal to be on the step and adjusting positioning around the table can be challenging with the bipolar pedal.” Q35: “The [laser] pedal is very stiff and so it takes a lot of pressure to engage or push down on the pedal and it causes my body to slide, which is not great when using a laser.

Pain

Exemplar quotations regarding pain are given in Table 3. Almost all participants reported some pain brought on by operating that they either experienced while operating or after operating. Participants reported pain in their backs, hands, neck, and shoulders. Some participants attributed back pain to prolonged time on standing stools “in a defensive position” (Q36) or after hunching down (Q37) and reported that their “back is killing [them] sometimes at the end of the day” (Q38). Participants reports that working in “a very small hole” and headlight use “definitely strains your neck” (Q39-Q41). After using bulkier or heavier instruments or after retracting, participants reported that their “hand does cramp up” and that their “hands would shake” (Q42-Q44). Participants reported multiple different treatments for pain, including targeted exercise, physical therapy, massages, and medications, including “high dose steroids” although many also reported that they “ignored it like any good doctor.” (Q45-Q50).

Table 3.

Exemplar Quotations: Pain

Theme	Exemplar Quotations
Back pain	Q36: “[I get back pain from] working on a standing stool… you have to always think about balance… kind of like in a defensive position” Q37: “I get a lot of lower back pain… I find I’m hunching too much.” Q38: “My back is killing me sometimes at the end of the day and it’s just harder with my kids… you’re carrying them a lot and sometimes you’re just like, I cannot continue on.”
Neck pain	Q39: “Microscope work hurts my neck more.” Q40: “All of the surgeries that require you to look straight down, intra-orally, or through a very small hole… that definitely strains your neck.” Q41: “Certain headlights are terrible for your neck… they cannot be adjusted properly to shine the light in the right place. You end up having to strain your neck to see what you’re doing.”
Hand pain	Q42: “[I usually get] some hand, thumb pain from dissecting, or fingertip pain from retracting.” Q43: “After a while your hand does fatigue and your hand does cramp up.” Q44: “[For] drug and sleep endoscopies… we are holding our arms in a certain position, holding up the scope for a really long time, and my hands would shake afterwards.”
Treatments for Pain	Q45: “I’ve definitely gotten massages.” Q46: “I had to go through a month treatment of high dose steroids” Q47: “Intentional yoga, for example, to be able to kind of stretch out and strengthen that side of my body. Massage on a regular basis.” Q48: “During residency I went to an acupuncturist for a little while for my neck.” Q49: “I’ve ignored it like any good doctor.” Q50: “I do yoga because of it. To prevent it… I have to stay in shape. I feel like it’s a part of my being healthy at work.”

Suggestions for Improvement

Exemplar quotes regarding suggestions for improvement are given in Table 4. Participants expressed multiple suggestions for improvement of instrumentation and equipment design. Frequently-cited was the desire for “different sizes of instruments” (Q51-Q52), the possibility of “adjustability to instruments” (Q53-Q54), or instruments that were designed to be used by a variety of hand sizes (Q55). Participants also expressed a desire for more equipment designed for smaller bodies, such as step stools, to be available (Q30) as well as “a middle ground between, like the massive neurosurgical [microscopes] and the kind of dinky older, non-powered, non-auto balance ones.” (Q56). In addition, participants asked for more open discourse about ergonomics and ensuring that set-ups “accommodate for all the surgeons in the room.” (Q57).

Table 4.

Exemplar Quotations: Suggestions for Improvement

Theme	Exemplar Quotations
Variety of Instrument Sizes	Q51: “Different sizes of instruments would help.” Q52: “I don’t think there should just be one size of instruments. I think that’s very strange… I don’t think it should just be there is one size Alfred. There should be the Alfred if you’re an eight and a half versus the Alfred if you’re a size six.”
Adjustable Instruments	Q53: “It would be great if there were some adjustability to instruments… some telescoping nature to some of the tools.” Q54: “With the microdebrider if that had an adjustable length or a shorter length, that that could be helpful.” Q55: “It certainly behooves everyone to take into consideration different heights, different sizes, different hand sizes in their instrument design… they can certainly target the most common sizes and the most common heights, but in order to make them universally usable, they will definitely have to make sure that the design is able to accommodate different surgeons physiques.”
More Equipment Sizes	Q56: “I think there maybe could be a middle ground between, like the massive neurosurgical [microscopes] and the kind of dinky older, non-powered, non-auto balance ones.”
Encouraging Discourse	Q57: “In the time out there is a spot for patient positioning… I think we should expand upon that and just make sure that everyone is happy with positioning and that it’s going to accommodate for all the surgeons in the room.”

Burden, Mentorship, and Sense of Belonging

Exemplar quotations are shown in Table 5. Many participants emphasized the time and mental burden of working to optimize their operating room for their body size, and that as trainees, ergonomics is “the last thing that people are willing to spend time on with you” (Q58-Q59). Participants also spoke about frequently having to ask for help from “really nice circulators and scrubs”, and how they “had to feel bad” and that it strained their relationship with staff (Q60). They discussed the time that it took to “roam operating rooms” to find equipment that they needed to operate (Q30, Q61). Participants felt that working in an environment not designed for someone of their size affected their sense of belonging in the surgical culture, feeling like they are “never going to as high as [they] could be if [they] had a different body.” (Q62-Q63), and that physically struggling with certain maneuvers given their body size gave them a negative view of their technical skills, and feeling that they “just don’t get it” (Q64-Q65). Participants reported “really important and empowering” experiences of similar-sized colleagues model adjustments they had made to how they use equipment (Q66-Q67), and on having attendings of all genders constructively focus on optimizing their ergonomics and adjustments for their body size. One participant reported that “there were a couple of attendings that [said] ‘You look uncomfortable. Let’s figure out why and fix that.’” (Q68-Q69).

Table 5:

Burden, Mentorship and Sense of Belonging

Theme	Exemplar Quotations
Burden	Q58: “You have to sort of stop the flow of a setup… and that takes significant time and I think, especially as residents, we don’t want to be using some of our training time for those types of adjustments.” Q59: “And as I think many surgical trainees can relate to that’s like the last thing that people are willing to spend time on with you. They just want to get their day moving forward. And so when you’re like, ‘Oh… can I move the microscope or adjust the table height?’ That’s a big ask.”
Asking for help	Q60: “I have to think about [my step stool] and I have to feel bad and [I say] “oh sorry, do you mind? I’m so sorry. Do you mind moving my standing stool?” and people like looking at you like “oh god, again”... and I have to do it every day.” Q61: “I have to roam operating rooms. I have to find really nice circulators and scrub nurses who will help me find my gloves. I have to ask the materials supply people to help me find gloves… it’s actually really stressful and really frustrating… And it’s like a lot of time that I spend on trying to find them. Just to be able to do my job.”
Sense of Belonging	Q62: “They’re not stocking enough of this type of equipment, if clearly it’s being pulled around... between rooms as the number of female surgeons goes up… I don’t feel like I don’t belong. But would I be more welcome?” Q63: “Sometimes you feel like you’re never going to as high as you could be if you had a different body.”
Negative view of technical skills	Q64: “There’s kind of like a culture where you know there’s something wrong with you or you just don’t get it if you think [specific surgical maneuvers are] uncomfortable” Q65: “Sometimes it makes me feel… more intimidated and a little bit more like I had more obstacles in the way of advancing surgically.”
Similar-Sized Role Models	Q66: “I think like some of the positive things are when I’ve had female attendings who have shared with me what works for them… so I’ve found those experiences to be really important and empowering” Q67: “What was empowering for me as a trainee was female attendings with similar hand size and similar physique showing me how to how to intubate, how to palm an instrument.”
Emphasis on Ergonomics	Q68: “One attending [said to me] ‘Hey, I know this has been a struggle for you… Why don’t we use this case? Why don’t we work on it?’… And I carried that with me. It doesn’t take a lot, it doesn’t need to be every time… but somebody to just take the time one time and give me the framework so I can figure it out for myself down the line. It’s huge.” Q69: “I can remember specifically there were a couple of attendings that really come to mind… who were just really dedicated to be like, ‘You look uncomfortable. Let’s figure out why and fix that.’”

DISCUSSION

In this study, we explored the ergonomic challenges faced by women in otolaryngology, identified equipment and instrumentation that was particularly problematic, gathered suggestions for how the operative environment could be improved, and explored the cultural aspects of ergonomic challenges. As the importance of ergonomics in surgery is increasingly recognized, all stakeholders, including those in instrument and equipment design, hospital purchasing, and surgeons themselves, must ensure that solutions address the needs of all surgeons, not just the majority. Our findings here can help inform the decisions these parties make.

Repetitive themes emerged during our interviews regarding pieces of equipment that were difficult or impossible to use by those in smaller bodies. Many participants reported difficulty finding surgical chairs that descended low enough. Concerningly, this was reported to be more prominent in newer chair models, suggesting that equipment design may not be becoming more inclusive despite increases in female surgeons. Participants also reported difficulty using microscopes for microlaryngeal surgery and challenges with operating with their arms outstretched, which they felt reduced their surgical performance. This is consistent with prior studies and particularly physically detrimental, as highlighted by the National Institute of Occupational Safety and Health (NIOSH) recommendation to avoid equipment that requires operators to hold limbs in an extended position over a prolonged period.^12,14,18

From a design standpoint, these difficulties underscore the importance of including smaller women in equipment prototyping.¹⁹ Microscopes could be re-designed to minimize the distance from the eyepiece to the lens to allow surgeons with shorter arms to operate comfortably, and surgical chairs that descend low enough should be standard. Step stools in a variety of heights would avoid the precarious yet common situation where surgeons are operating from stacked step stools. From a practical standpoint, hospitals should consult with surgeons of a variety of physiques before making purchases, particularly because those in leadership roles are more likely to be male and may not appreciate equipment limitations.²⁰

Several surgical instruments were specifically mentioned as difficult to use. The most dominant theme that arose was a preference for smaller instruments and difficulty with using larger instruments. The challenges associated with instrument size have been highlighted by other studies. A recent survey by Weinreich et al. that included physicians of all specialties but did capture 20% otolaryngologists found that 60% of respondents felt that their hand size affected their ability to use instruments; this figure jumped to 72% in those with a glove size of 6.5 or less.²¹ In this and other studies, controlling for glove size, females had a 3 times odds of struggling with instruments as compared to males, likely attributed to decreased grip strength.^4,21,22 Glove size is strongly correlated with hand circumference rather than finger length, and therefore instrument design based on glove sizes fails to capture the range of surgeon’s finger spans.²³ When testing a laparoscopic stapler device in their sample, one group found that the trigger span was too long for 69% of females versus 22% of males.²³ Universal design is an established concept, and instrument designs that are usable independent of hand size have been proposed, but have not yet become widespread.^24,25 In addition, common instruments should be available in a range of sizes, important at both the design and hospital purchasing stages, as even those instruments with small sizes manufactured are often not available to individual surgeons.

We also found that most of our participants experienced regular pain while or after operating. Work-related muscular injury in surgeons is an important issue in all genders and body sizes, as high rates of injuries has been reported in both male and female otolaryngologists.^7,10,11,26 A recent systematic review found that a higher rate of work-related discomfort in female otolaryngologists.²⁷ Many participants noted frequent hand pain and cramping, consistent with prior literature showing higher rates of hand pain amongst female otolaryngologists.¹⁰ We speculate this may be attributed to using instruments not optimally designed for their hand size. Interestingly, when asked about the effects of pain, multiple participants commented that pain from operating affected their role as a mother. Although not specifically addressed in our study, prior publications have shown an exacerbation of work-related injuries during pregnancy in female orthopedic surgeons, a finding that requires further investigation in otolaryngology.²⁸ Pain and injuries from work have serious consequences, including requiring lifestyle modifications, medications, surgery, time off work, or early retirement.²¹ Furthermore, a negative perception of one’s personal health reduces physician job satisfaction, which may contribute to burnout and workforce attrition.²⁹ Addressing factors that may disproportionately affect women is important as we work to diversify our workforce and retain the increasing numbers of female trainees.³⁰

An additional consideration for retention of female trainees is creating an environment and culture that feels inclusive to all body sizes and genders We found that most participants remembered specific mentors who gave them the time, space, and tools to figure out how to optimize their ergonomics, and carried those moments with them. Conversely, participants that learned to operate in a way that felt physically challenging for them developed a negative impression of their technical skills. These findings are in line with prior studies in other specialties.^31,32 Having role models with a similar demographic background to oneself is important for career advancement in academic medicine, and the physical aspects of surgical ergonomics is an additional reason why representation at all levels is important.^33,34

Another aspect of ergonomics that many of our participant noted is the time and mental burden of operating in a space and with equipment that has not been designed for someone of their size. In a busy surgical practice, having to spend extra time to get appropriate equipment can create an additional responsibility and barrier for female surgeons.³⁵ In addition, having to frequently ask operating room staff for assistance can strain relationships with staff, which are already more difficult to navigate for female surgeons.^36,37 Overall, the physical and mental challenges of a material environment not adapted to the female body contribute to a sense of alienation from the surgical culture.

Multiple non-physical interventions for improving ergonomics have been proposed, both by our participants and others, including improving ergonomic education, encouraging a culture of taking breaks, and open discussion about ergonomic challenges.^38–40 Specific changes, such as positioning the screen just below the horizontal gaze in endoscopic surgery, performing in-office otologic procedures with the patient supine, and avoiding neck flexion during otologic surgery have also been proposed, and certainly apply.^41–43 Some of these maneuvers may be difficult for smaller women, however, who struggle to perate with equipment that is not fit to their body size. Many of our participants expressed ways in which they were actively working on their ergonomics, whether with regular exercise or by asking operating room staff to correct their posture.⁴⁴

It is worth noting, however, that the practice of ergonomics is defined as fitting the job to the person, not the reverse.⁴⁵ While it is certainly important for individuals to optimize themselves, we must also consider changes to our physical environment. The diversity of surgeons has grown and the range of surgeon physiques has expanded; therefore, physical equipment and instrumentation design should evolve accordingly. A more adaptable physical environment will benefit surgeons of all sizes, and stepping up to this challenge as otolaryngologists will allow us to prioritize the physical wellbeing of our entire workforce and serve as an example across surgical specialties.

There are multiple limitations to our work. Our use of semi-structured interviews allowed us to gain in-depth information from our participants; however, each interview varied slightly from the next and cannot be directly compared. Although we reached thematic saturation, we interviewed a small sample of physicians and it is possible that important issues were missed due to our sample size. The researchers personally knew participants and therefore participants may have felt pressure in how they answered the questions, and the selection of participants known to the researchers may have introduced additional selection biases. For example, we may have unintentionally invited participants who were more likely to suffer from ergonomic challenges or had expressed an interest in ergonomics. We used a Straussian method, with literature review performed prior to data collection, which allowed us to focus our data collection but may have biased our interpretation of data. We also did not include any left-handed surgeons, a group with unique ergonomic concerns. Our next step, informed by the insights gathered with this qualitative study, is to formulate a comprehensive survey of the ergonomic experience of female otolaryngologists to obtain a broader perspective on the challenges experienced.

CONCLUSION

In this study, we interviewed 14 female otolaryngologists regarding the impact of surgical ergonomics. Participants spoke about struggles with equipment and instrumentation that did not fit their body size and reported pain associated with operating. Participants suggested areas for improvement, including equipment modifications and a wider variety of instrument sizes. These findings can guide more inclusive instrument design and purchasing decisions.