Dermatologic ergonomics: Straighten up and fly right

By Warren R. Heymann, MD, FAAD
June 28, 2023
Vol. 5, No. 26

My posture has never been proper, having a proclivity to slouch. “Stand up straight, son!” my father would admonish. When I was young and supple, I would half-listen to the advice, usually reverting to my standard (incorrect) position. I still do, unfortunately, although I consciously try to adjust. As our practice has grown, I increased the number of microscope hours for dermatopathology. I needed to invest in ergonomically suitable microscope eyepieces and a chair with excellent lumbar and back support. Without those modifications, by the end of the day, I felt as though I needed a chiropractic adjustment.

Ergonomics is defined as “an applied science concerned with designing and arranging things people use so that the people and things interact most efficiently and safely.” (1) During my residency 40 years ago, the only training on ergonomics I recall was an impromptu conversation with my stellar attending Gary Brauner, MD, FAAD, who told me that when I open up my office (that was the expectation then) to invest in adjustable examination tables, or one day my back would regret it. Great advice!

Of the hundreds of commentaries I have written, this one tops the list as most important, because if you become disabled and cannot practice, all other editorials are meaningless. In their outstanding viewpoint, Bhatia et al opine: “It is time that dermatologists learn to take care of themselves…Within health care, NIOSH [National Institute for Occupational Safety and Health] provides suggestions for evaluating work-related equipment to optimize proper positioning for varying of work practices to avoid high-risk procedures, and for necessitating periodic training and reassessment of health care providers.” (2)

Chan et al surveyed the literature from other specialties to determine if ergonomic lessons could be learned that are applicable to dermatologists and dermatologic surgeons. (3) For example, they refer to the article by Dehghan et al in which 122 male dentists in Iran were randomized to an intervention group (n=52) that received multifaceted ergonomic training and a control (n=50) group that received no training. Musculoskeletal pain was evaluated 3 times during the course of their 6-month trial using the Nordic Musculoskeletal Questionnaire. The authors found a statistically significant reduction in musculoskeletal disorders after the intervention, concluding that “the multifaceted ergonomic intervention program, which included improving working conditions, identifying ergonomic risk factors, regular exercise, and discussion group meetings, could decrease the prevalence of musculoskeletal disorders in dentists.” (4)

How often is ergonomic training provided in dermatology residency and fellowship programs? Deo et al surveyed ACGME-approved programs via the Association of Professors of Dermatology, asking 28 questions encompassing 3 sections: demographics, education and training in ergonomics, and workstyle practices. There were only 70 respondents (58 residents, 12 fellows); the authors acknowledge the potential for selection bias, with the possibility of a greater response from those with practice-related musculoskeletal difficulties. Programs with at least 15 residents were significantly more likely to use ergonomic equipment than smaller residencies. (5) In our small program, we may be ergonomically attuned, but we do not have a formal curriculum or assessment in place.

Dermatologists, dermatologic/Mohs surgeons, and dermatopathologists are at risk for musculoskeletal injuries. This was discussed recently in DermWorld: “Dermatologists perform some of the highest numbers of procedures among any specialty, noted Ashish C. Bhatia, MD, FAAD, associate professor of clinical dermatology at Northwestern Medicine in Chicago. Among them are biopsies, cryosurgery, injections, excisions, laser surgery, and Mohs surgery with reconstructive repairs. Dermatologists tend to hunch and lean forward with their neck extended, putting a significant amount of strain on their cervical spine, he said. Additionally, sitting at the microscope for hours without a break, as dermatopathologists often do, can lead to a ‘locked-in’ posture.” Particular attention should be paid to examination and surgical tables, lighting, chairs, trays, magnification eyewear, microscopes, and computer workstations. (6) Creative solutions may be implemented. An example is the use of an adjustable standing desk over the countertop for the inking station where Mohs specimens are grossed and inked, as Mohs surgeons and histotechnologists are likely of discrepant heights. (7)

The necessity to take breaks, stretch, and perform strengthening exercises during the workday cannot be overemphasized, in order to decrease the risk of injury and disability. Please see the reference by Carley et al for specific examples. (8) At the microscope, I insist that all of us get up and stretch hourly.

In conclusion, a major ingredient in securing a long, successful career in dermatology is to avoid musculoskeletal injury by paying attention to ergonomics. You should heed the advice in the subtitle of the article by Bhatia, et al: Sit up straight, stand up tall, and carry a sharp scalpel.

Point to Remember: Ergonomic training should start with residency and continue throughout a career to avoid potentially serious musculoskeletal injury.

Our expert’s viewpoint

June K. Robinson, MD, FAAD
Professor Emeritus of Dermatology
Northwestern University Feinberg School of Medicine

To all derms: This means you

For those of you who glance at the picture of people grossing tissue or read the first paragraph and decide a dermatopathologist has nothing to offer you: stop and think about how often you bend over a patient to use a dermoscope, perform a skin biopsy or an elliptical excision. Do you have pain and stiffness in the neck, shoulders, and lower back and headaches? Perhaps you will realize this warning is relevant to you. Now, what do you do?

1. Empower a member of your team to observe you and your team as you work and record the amount of time you bend over a table or work with your neck flexed at an angle of 15o or more. You may need this data to take to your employer to support your request for an ergonomically safe workplace. Expect push back from your employer. The employer is focused on reducing costs. From the employer’s perspective, if you become disabled you are no longer their concern and they can hire another physician.

2. Check the terms of the disability policy offered by the institution. Ideally, you want one that covers your ability to perform your “own occupation.” If you can obtain more coverage by paying an additional fee, then consider making the investment in your own future. May you never need it!

3. Have all of your examination (treatment) tables adjust with a foot pedal. A narrow table with a head rest and adjustable positioning of the back and legs will allow access to many areas of the patient’s body. Your patients will be more comfortable if properly positioned. Hand controls require bending over to pick up the device. If the electrical cord to the table runs across the floor, get an easily removable cover placed over the cord to prevent tripping on the cord. The cleaning crew can remove the cover. This solution avoids your employer’s push back over the added expense of installing an electrical outlet in the middle of the floor for your electrical examination table. Many dermatologists reduce expenses by having one procedure room and the rest of the rooms set up with examination tables with a fixed base. The patient needs to climb onto the table using a small step at the bottom of the table without support for their arms. When older patients find this very challenging and risk falling, the office staff must move patients to the one procedure room to be able to render care. This wastes valuable time and slows down the office.

4. If your assistant is a different height than you are, get standing stools in each room. Neither of you should bend over the table.

5. Try to perform procedures in a seated position using a stool with sternal support.

6. Start regular exercise to strengthen your core supporting muscles along the spine. It is best to start yoga or Pilates or both with a trainer. The goal is about using the body’s smaller, accessory muscles to work against one another to align the spine, take force off the lower back and neck, and improve posture. This regular body maintenance continues for life.

7. Set the alarm on your watch to remind you to take a break every hour to stretch. I prefer back bends with my hips supported from the rear on a counter. Then, I lean back over the counter with my torso and neck in a line slowly lowering your back one vertebrae at a time from T1 to L1and come upright slowly. Warning, you need toned abdominal muscles to do this. Start with one or two and work up to 5.

8. If you start to get tingling in your fingers, do not delay seeing a doctor. Shaking if off will only lead to a herniated disc in the neck and possible permanent nerve loss in your hand, which can be career ending.

Lastly, the AAD could make recommendations and tips about an ergonomically safe office in the practice management section of the AAD website. This proactive member support could be included in the office optimization section.

1. https://www.merriam-webster.com/dictionary/ergonomics (accessed July 24, 2022)

2. Bhatia AC, Xu S, Robinson JK. The Need for Ergonomics Education in Dermatology and Dermatologic Surgery: Sit Up Straight, Stand Up Tall, and Carry a Sharp Scalpel. JAMA Dermatol. 2017 Jan 1;153(1):13-14. doi: 10.1001/jamadermatol.2016.4069. PMID: 27892979.

3. Chan J, Kim DJ, Kassira-Carley S, Rotunda AM, Lee PK. Ergonomics in Dermatologic Surgery: Lessons Learned Across Related Specialties and Opportunities for Improvement. Dermatol Surg. 2020 Jun;46(6):763-772. doi: 10.1097/DSS.0000000000002295. PMID: 31876576.

4. Dehghan N, Aghilinejad M, Nassiri-Kashani MH, Amiri Z, Talebi A. The effect of a multifaceted ergonomic intervention program on reducing musculoskeletal disorders in dentists. Med J Islam Repub Iran. 2016 Dec 28;30:472. PMID: 28491847; PMCID: PMC5419222.

5. Deo N, Carley SK, Mullen B, Vidal NY. Ergonomic education in dermatology training: A survey. Australas J Dermatol. 2022 May;63(2):e164-e166. doi: 10.1111/ajd.13788. Epub 2022 Jan 31. PMID: 35099069.

6. Carol R. Watch your back! Focusing on ergonomics can help dermatologists avoid a career-ending injury. Dermatology World February 1, 2021. https://www.aad.org/dw/monthly/2021/february/feature-ergonomics

7. Schauder DM, Nijhawan RI. Implementation of an adjustable standing desk inking station for improved ergonomics in Mohs surgery. J Am Acad Dermatol. 2021 Mar;84(3):e131-e132. doi: 10.1016/j.jaad.2019.08.056. Epub 2019 Aug 29. PMID: 31473293.

8. Carley SK, Strauss JD, Vidal NY. Ergonomic solutions for dermatologists. Int J Womens Dermatol. 2021 Aug 15;7(5Part B):863-866. doi: 10.1016/j.ijwd.2021.08.006. PMID: 35028404; PMCID: PMC8714568.

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