Female Surgical Ergonomics in Otolaryngology: A National Survey Study

Abstract

Objectives:

To assess the nature and impact of surgical ergonomic challenges experienced by female otolaryngologists.

Study Design:

National survey study

Methods:

We distributed a survey study to female otolaryngologists throughout the United States. The height and glove size of participants reporting difficulties with equipment and instruments were compared to those not reporting difficulties.

Results:

Ninety-six female otolaryngologists participated in our study, comprised of 43% residents, 10% fellows, and 47% attendings. Ninety percent of participants reported difficulties using equipment and 77% of participants reported difficulty with instruments, the most common being nasal endoscopic instruments (28%). The vast majority of participants reported pain during and/or after operating (92%). Head and neck (53%) and rhinology (44%) were identified as particularly challenging specialties, but only 25% of participants reported that ergonomics affected their career plans. Participants felt that adjustable equipment (60%), a variety of sizes of instruments (43%), and more discussion around ergonomics (47%) would help. Respondents reported adjusting the operating room to accommodate their size took extra time (44%) and was a mental burden (39%). Participants reporting difficulties with operating room equipment were significantly shorter than those without difficulties (64 inches vs 67 inches, p=0.037), and those reporting difficulties with instruments had a smaller median glove size (6 vs 6.5, p=0.018).

Conclusions:

Surgical ergonomics represent a challenge for female otolaryngologists, particularly those with smaller hands and shorter height. Partnering with industry, we must address the needs of an increasingly diverse workforce to ensure that all surgeons can operate effectively and comfortably.

INTRODUCTION

Ergonomics, the study of the interaction between a worker and their job environment,¹ is receiving increased attention in the field of surgery.^2-4 The occupational need for prolonged standing, prolonged holding of ergonomically suboptimal postures, use of varied equipment, and operating with individuals of different sizes all predispose surgeons to ergonomic challenges.^5–7

Otolaryngology is particularly predisposed to ergonomic challenges considering the prevalent use of endoscopes and microscopes, focus on small cavities, and necessity of frequent headlight and loupe use.^7,8 A recent review examined surgical ergonomics in otolaryngology, and found a high prevalence of work-related musculoskeletal disorders.⁹ Importantly, the authors identified multiple studies that found effective ergonomic interventions, including the use of novel equipment and instrumentation. Despite this, the use of more ergonomic devices and equipment has not been widely adopted in our field.

Further, surgery is a traditionally male-dominated field and the instrumentation and equipment have historically been designed for male bodies. Women’s bodies differ significantly from male bodies in size and strength. While all body sizes present unique ergonomic challenges, recent studies have shown higher rates of ergonomic difficulties and work-related musculoskeletal pain in women.^4,10–12 Challenges with ergonomics and concerns about the physical demands of surgical fields have been shown to affect surgeon recruitment, a finding which likely extends to surgeon retainment and advancement as well. ¹³ Given this, attention to the ergonomics of female otolaryngologists is important for continued female otolaryngologist recruitment and advancement.

A prior study by our group examined the ergonomics of female otolaryngologists by qualitatively analyzing open-ended interviews ¹⁴. We found high rates of ergonomic challenges, exacerbated by specific instruments and equipment, as well as frequent work-related pain and cultural challenges associated with ergonomics. While these interviews helped us gain in-depth insight into the ergonomic difficulties experienced by female otolaryngologists, we had a limited number of participants due to the qualitative study design. We thus designed this present survey to assess the nature and impact of ergonomic challenges experienced by a larger group of female otolaryngologists.

METHODS

Survey Tool Development

Our group previously explored the surgical ergonomic difficulties experienced by women in otolaryngology in a qualitative study.¹⁴ The themes identified were used to develop a 58-item questionnaire (supplement 1), designed to assess the ergonomic challenges experienced by female otolaryngologists. Demographic and physical stature information was collected, as well as questions regarding difficulties using surgical instruments and equipment, pain associated with operating, effects of ergonomics on career plans, and cultural aspects of ergonomic challenges. Question formats were multiple choice, multiple response, yes/no, and free text. Participants were permitted to skip questions.

Subject Recruitment and Survey Administration

The study was approved by the Weill Cornell Institutional Review Board. The study subjects included female otolaryngology residents, fellows, and attendings. Subjects were invited to participate by emails to known contacts, via social media postings, as well as through distribution to US residency program directors with a link to participate in the ergonomic survey. The survey was described as a ”study that is examining the specific ergonomic challenges experienced by women in otolaryngology,” with the aim of collecting “reports of ergonomic challenges with equipment and instruments, impact of ergonomics on training, and the impact of ergonomics on career decisions.” Those receiving recruitment materials were encouraged to distribute further to others they felt may be interested in participation. The survey was administered via REDCap (Research Electronic Data Capture) tools hosted at Weill Cornell.^15,16

Statistical Analysis

Statistical analysis of survey responses was performed with Stata version 16 (StataCorp, College Station, TX, USA). Descriptive statistics were generated from the data. The height and hand size of participants reporting difficulty with equipment and instruments were compared to those not reporting difficulty via Mann Whitney U testing.

RESULTS

Demographics

A total of 96 participants completed the survey. All participants identified as females. Forty-one (43%) of participants were residents, 10 (10%) were fellows, and 45 (47%) were attendings. Participants had a median glove size of 6.5 (IQR: 6–6.5), a median height of 64 inches (IQR: 62–66), and 90/96 (94%) were right-handed. Participants had been in practice (including training) for a median of 6 (IQR: 4–12) years and were predominantly practicing general otolaryngology (N=33, 37%), followed by laryngology (16, 18%), pediatric otolaryngology (13, 14%) rhinology (11, 12%), head and neck (8, 9%), facial plastics (6, 7%), and otology (3, 3%). Most (82, 87%) participants were affiliated with academic centers. Participants spent a median of 16 (IQR: 10–30) hours in the operating room each week.

Problems Using Equipment

Difficulties using equipment were reported by 86/96 (90%) of participants. Specific equipment cited as challenging are shown in table 1. Most (62, 65%) felt that this difficulty was due to their height, 20 (21%) due to their hand size, and 46 (48%) due to their arm length. Also, 14 (15%) of participants reported difficulty obtaining appropriately-sized gloves, and 21 (22%) reported difficulty finding step stools.

Table 1. Equipment.

Number and percentage of participants who reported difficulties using various pieces of operating room equipment.

Equipment	Participants with Difficulty (N, %)
Microscope	47 (49%)
Chairs	45 (46%)
Tables	24 (25%)
Beds	21 (22%)
Pedals	41 (43%)
Steps	38 (40%)
Headlights	30 (31%)
Overhead Lights	49 (51%)
None	10 (10%)

Problems Using Instruments

Overall, 74 participants (77%) reported difficulties using instruments. Specific instruments reported as difficult are detailed in Table 2. The most common reason leading to difficulties was hand size (59 participants, 61%), followed by arm length (19, 20%) and height (14, 15%). Of those surveyed, 66 (69%) reported that they had to use instruments differently than they were designed, with specific instruments cited shown in Table 2. Thirty respondents (31%) felt the size of instruments limited their technical abilities, and 41 (43%) felt the design of instruments limited their technical abilities. Many participants felt that different instrument design would improve their technical abilities (65, 68%), and experience operating (76, 80%).

Table 2. Instruments.

Number and percentages of participants who reported difficulty using various surgical instruments, as well as number and percentage who felt that they needed to use instruments differently than they were designed.

Instrument	Participants with Difficulty (N, %)	Participants Modifying Use (N, %)
Drills	19 (20%)	17 (18%)
Flexible Endoscopes	11 (11%)	12 (13%)
Rigid Endoscopes	21 (22%)	21 (22%)
Ligasure	15 (16%)	7 (7%)
Retractors	24 (25%)	17 (18%)
Needle Drivers/Clamps	16 (17%)	16 (17%)
Clip Appliers	17 (18%)	10 (10%)
Nasal Endoscopic Equipment	27 (28%)	23 (24%)
Suction Bovie	4 (4%)	4 (4%)
Microdebrider	9 (9%)	7 (7%)
None	22 (23%)	30 (31%)

Pain Associated with Operating

A large majority of participants (88, 92%) had pain either while operating (10, 10%), after operating (24, 25%), or both while and after operating (54, 56%). Common locations of pain reported included neck (73, 76%), back (57, 59%), hands (33, 34%), shoulders (38, 40%), and arms (14, 15%).The most commonly-cited cause of pain was long operative time (74, 77%), but 38 (40%) also cited specific types of operative cases as causing pain – most commonly those requiring a microscope, endoscopic sinus surgery, and those necessitating a headlight. A minority of patients (15, 17%) sought formal medical evaluation for pain. Treatment that patients sought for pain included massage (54, 56%), intentional exercise (54, 56%), physical therapy (16, 17%), medications (24, 25%), surgery (2, 2%), and acupuncture (4, 4%). Common medications reported included nonsteroidal anti-inflammatories, acetaminophen, steroids, and muscle relaxants.

Career Trajectories

Specialties most-cited as particularly challenging included head and neck (51, 53%), rhinology (42, 44%), otology (39, 41%), and laryngology (32, 33%). Most respondents did not feel that ergonomics affected their career plans (72, 75%), but the most common career decision affected by ergonomics was choice of specialty (15, 16%). Few respondents reported that ergonomics affected their choice for academics (2, 2%), private practice (3, 3%), or location of practice (3, 3%).

Suggested Changes

Participants felt that multiple changes to the operative environment could help them operate more effectively or comfortably. These included adjustable instruments (38, 40%), a variety of sizes of instruments (41, 43%, needle drivers, clips and endoscopic equipment commonly cited for both of the above), adjustable equipment (58, 60%), a variety of sizes of equipment (36, 38%, including bed, chairs, microscopes, and step stools for both of the above), and more discussion around ergonomics (45, 47%).

Cultural Aspects

A slight minority of respondents (42, 44%) felt that adjusting their operating room set up to accommodate for their size took extra time, 37 (39%) felt that it was a mental burden, 65 (68%) felt that they had to ask for help from others frequently due to their size. A minority (22, 23%) felt that their experience operating as someone of their physical size affected their sense of belonging as a surgeon, and 36 (38%) felt that it affected their perception of their own skill. A slight majority (50, 52%) had been taught during training to operate in a way that did not feel feasible for their body size. Despite this, 82% of respondents (79) reported positive experiences with ergonomics, including similar-sized superiors and peers modeling ways to modify operative techniques (51, 53%), superiors and peers emphasizing good ergonomics (58, 60%) and helping to troubleshoot ergonomic difficulty (42, 44%), and equipment purchased for ergonomic purposes (7, 7%).

Physical Characteristics of Participants with Difficulties

There was a significantly shorter height of respondents reporting difficulties with operating room equipment versus those with none (median 64 inches versus 67 inches, p=0.036), but no significant difference in glove size (median 6.5 versus 6.5, p=0.075). There was a significantly smaller glove size of participants reporting difficulty with instrumentation versus those with none (median 6 versus 6.5, p=0.018), but no difference in height (median 63.5 versus 65.6, p=0.05).

DISCUSSION

In this study examining specific surgical ergonomic challenges experienced by female otolaryngologists, we recruited 96 subjects in various subspecialties, at various stages in training, and of various physical sizes. Our findings confirm many female otolaryngologists struggle with surgical ergonomics - 90% of participants report difficulty with surgical equipment, 77% with surgical instrumentation, and 92% reported pain associated with operating. This struggle with ergonomics had further implications as 44% of participants felt that adjusting their operating room took extra time and 39% felt that it was a mental burden. Notably, difficulties using surgical equipment was more common amongst shorter surgeons, and difficulties with instruments was more commonly reported among surgeons with smaller glove sizes.

Prior work, both by our group and others, has explored unique ergonomic challenges experienced by female surgeons. In a survey of American College of Surgeons members, a higher rate of occupational-related musculoskeletal injuries was found among female versus male surgeons.¹⁷ Similarly, among general surgeons, women were found to have a five-fold odds of physical complaints when using laparoscopic devices, findings which were replicated in orthopedic surgeons.^18–20

In otolaryngology, an ergonomically high-risk field, no prior work had specifically examined the surgical ergonomic hazards experienced by females. For that reason, our group recently conducted a qualitative interview study examining the perspectives of female surgeons on surgical ergonomics.¹⁴ Our participants frequently reported difficulty with a variety of surgical instruments and operating room equipment, as well as frustration with the lack of a diversity of instrument sizes available, difficulties with operating room setup due to their size, and frequently having to ask operating room staff for assistance. While these findings were meaningful, the small sample size limited generalization to a broader population.

To assess how commonly female otolaryngologists face surgical economic challenges, the design of our survey was guided by the findings in our prior work. Furthermore, the survey allowed us to assess for specific pain points and potentially clarify avenues of innovation and improvement. Overall, the results of the survey confirmed the substance of our qualitative interviews.

Difficulties with instruments were very common, which applicants attributed most often to hand size. Of interest, no single piece of equipment was noted to be challenging for most respondents – the instrument with the highest percentage of participants reporting difficulty with was nasal endoscopic equipment at 28%. Rather, different participants indicated that different instruments were more challenging. Similarly, many participants reported modifying their use of various instruments. While these findings do not identify a single obvious culprit causing challenges with instrument handling, it implies that surveyed female surgeons likely each developed unique solutions to cope with their individual difficulties.

In addition, those reporting difficulty with instrumentation had, on average, a smaller glove size (6) than those without difficulties (6.5). This corroborates prior research in general surgery that correlated smaller hand size with more difficulties with instrumentation in minimally invasive surgery.²¹ A recent pilot study found a decrease in hand strength and dexterity and increase in hand pain after performing endoscopic sinus surgery.²² The mean glove size in their cohort was 7, and we postulate that these findings would be even more pronounced in our cohort with smaller size hands.

Similarly, many of our participants struggled with surgical equipment, most commonly microscopes, chairs and overhead lights, with height and arm length given as the most frequent reasons. Participants reporting difficulty with equipment were significantly shorter than those without difficulty, highlighting the heightened need for adjustments to equipment to accommodate shorter surgeons. Significant differences in the ranges of heights accommodated by surgical stools were previously noted.²³ Within otolaryngology, microscopic otologic surgeries have been associated with poor surgical ergonomics due to neck and back flexion, regardless of gender.^24,25 Similarly, the ergonomic hazards of microlaryngoscopy are well-described.^26,27 However, no prior study has examined how shorter arms impact surgeon positioning and ergonomics during microscopic surgery. This is likely particularly relevant in laryngeal surgery where longer working distances and greater extension of the upper extremity are required. Objective measurements of body positioning for people of different sizes should be performed when considering microscope re-design.

While the high rates of pain noted by our study is not a novel finding, it remains an important area of improvement. The most common locations of pain, the neck and back, are expected, however 34% of our participants also reported pain in their hands, and 15% in their arms. We suggest that this may be due to smaller and less muscular hands and arms than those for whom surgical instrumentation was designed. Pain was most cited in association with long cases. This is consistent with prior findings that holding a single posture for a prolonged time is an ergonomic hazard.^28,29 Endoscopic sinus surgery was also cited as particularly pain-inducing. In addition to the monitor position and lack of arm support, we postulate that some of the pain reported by our participants may be related to high rates of difficulties using endoscopic instruments also found in our survey.³⁰

Unfavorable ergonomics also have a negative impact beyond physical discomfort. Many participants reported difficulties with extra operating room set up and needing to ask staff for help. Prior work has shown that the relationships of female surgeons with operating room staff is already more strained than those of their male counterparts, and these ergonomic issues may add more stress to these relationships, with female surgeons being perceived as more demanding in their effort to create a more comfortable and safe set up to operate.^{31, 32}

Reassuringly, most participants did not feel that surgical ergonomics affected their career choices or trajectory. Nevertheless, a significant minority felt that surgical ergonomics affected their sense of belonging as a surgeon or perception of their own skill. Just as academic self-concept influences student performance, surgeon self-concept likely influences the performance and trajectory of otolaryngologists, particularly residents and junior attendings.³³ Working to address the ergonomic issues faced by female surgeons may facilitate addressing the underrepresentation of women in the senior ranks of otolaryngology.

Multiple interventions have been proposed to help address poor surgical ergonomics. These include modifications to patient and surgeon positioning, increased training, and increased focus on ergonomics.^3,34–36 A pilot study in general surgery found that surgical residents have poor knowledge of ergonomic principles and a high rate of musculoskeletal symptoms, but that a surgical ergonomic workshop helped to improve both ergonomic knowledge and musculoskeletal symptoms.⁴ However, the adoption of these practices has been underwhelming and inconsistent, likely as they require additional time and attention from already busy surgeons.^2,37

While interventions including education, focus, and training are certainly important, some of the suggestions proposed by our participants should also be considered to promote ergonomic modifications inclusive of all surgeons, regardless of gender. Importantly, many of their suggestions, such as adjustability or varied sizing of instruments (suggested by 40% and 43% respectively of participants), and adjustability or varied sizing of equipment (60% and 38%, respectively) were related to modification of the physical environment rather than surgeon’s handling or posture. Using improperly sized equipment and instrumentation is unlikely to be overcome by any interventions other than improvement in their physical aspects. However, many (47%) of our participants also agreed that more discussion around ergonomics could improve their surgical ergonomics.

Advocacy by organized groups is critical to help resolve these issues. The AAO-HNS Section for Women in Otolaryngology (WIO) has focused on surgical ergonomics a critical area for investigation and education. An AAO-HNS sponsored webinar funded by WIO endowment grant was presented by the co-founder for the Society of Surgical Ergonomics in October 2022. In the last 3 years, 5 unique grant applications have been submitted to the WIO on the topic of gender differences in surgical ergonomics, including pregnancy and its effects on surgical ergonomics. Gender differences in instrumentation and the OR environment may reflect the lack of women otolaryngologists’ representation in industry.

There are multiple limitations to this study. First, as a survey study we are susceptible to response bias, which is particularly relevant given our distribution method to our personal networks and those participants’ networks. Individuals that chose to participate may have been more likely to suffer from surgical ergonomic issues than non-participants. A recent review identified 1719 female otolaryngologists in the United States,³⁸ and our survey captured approximately 6% of these. As the survey was informally distributed and the number of people who saw the survey invitation is unknown, we were unable to calculate a response rate. We also did not ask about grip strength, a potentially important contributor to ergonomic comfort with surgical instruments. We provided a set list of multiple-choice options to participants, which may have caused participants to select options they would not have spontaneously produced. To minimize this, we phrased all questions neutrally, avoided leading questions, and gave the options to skip or select “none” for all questions. We did not include male participants in this study, and this limits our ability to comment on the comparative prevalence of ergonomic challenges between sexes.

CONCLUSIONS

Female otolaryngologists have a high rate of ergonomic difficulties with surgical instruments and equipment, and the majority of female otolaryngologists report pain associated with operating. Challenges with instruments and equipment were correlated to small hand size and height, respectively. Ergonomic issues may exacerbate existing underrepresentation of women in otolaryngology leadership and should be prioritized to ensure occupational safety of our increasingly diverse workforce.

Supplementary Material

Supinfo

Supplement 1: 58-item questionnaire designed to assess the prevalence of ergonomic challenges experienced by female otolaryngologists