Medical training covered a lot of things. Anatomy, pharmacology, suturing, how to read a pathology slide, how to talk to a family in a hard conversation. What it did not cover was how to maintain good ergonomics while examining a patient or operating.
I had an ergonomics head start on most everyone else: my mother is a physical therapist. Growing up involved lots of "correcting" my posture and body mechanics, sometimes with gentle prods (effective for both uninterested adolescents and animal husbandry it would seem). Incorporating good ergonomics into dermatology practice felt less like learning a foreign language and more like adapting previously learned habits for the operating suite. The more proceduralists I meet, the more that I think they would benefit from having heard similar lessons on body mechanics early in their careers.
The Scale of the Problem
Surveys of Mohs surgeons consistently find musculoskeletal symptoms in the great majority of respondents — figures as high as 90% have been reported in the literature. That is not a fringe finding. Procedural medicine asks the body to sit in awkward, sustained positions for long periods, often with a forward head posture and loading the shoulder girdle in bizarrely uncomfortable ways. The result is fairly predictable.
I have no interest in being part of that statistic, and I do not think we should accept it as the cost of doing this work. The good news is that most of the interventions that actually move the needle are not exotic. They are a handful of small adjustments done consistently over time.
What Actually Matters
The first principle is that the enemy is not simply "bad posture." It is prolonged static posture. A position held motionless loads tissues continuously: muscles fatigue and blood flow drops under sustained low-level load. Good ergonomics is dynamic, not a single pose to lock into — aim for a neutral baseline, then keep subtly moving within it.
The second principle is that two levers move the needle, and you need both: optimize the workspace, and train the body. You cannot out-exercise a broken workstation, and a perfect workstation will not fix a deconditioned body.
Ergonomic loupes
Optics are a high-leverage piece of equipment, and one that can positively or negatively influence cervical strain.
- Declination angle. A steeper declination angle lets the neck stay closer to neutral. Most major manufacturers can adjust this at fitting; many surgeons never ask.
- Working distance. Longer than you expect, and it should be measured while you are standing fully upright — not in the slumped posture most of us unconsciously adopt at a fitting. A loupe fitted to a hunched stance encodes that posture into every case you do.
- Go ergonomic if you can. Designs with prismatic or steeper-declination optics measurably lower neck inclination and trapezius load. If you wear loupes for a living, ergonomic loupes are worth the upgrade.
Stool, table, and anti-fatigue mat
A saddle stool or stool with a sternal support arm will keep you feeling better. Table or patient height should be set so the shoulders stay relaxed and the elbows sit near 90 degrees. When standing, an anti-fatigue mat reduces lower-extremity load and, as a quiet bonus, forces the small subconscious weight shifts that interrupt static posture. Alternating sitting and standing through the day is one of the easier ways to vary the load.
Postural resets and microbreaks
- 20-20-20. Every 20 minutes, look at something at least 20 feet away for at least 20 seconds to reduce accommodative eye strain.
- 60–90 minute resets. A short standing break between cases — even thirty seconds of upright, shoulders back, lumbar extension.
- Between-case micro-resets. The most underrated of the three. Anchor them to a trigger you already do (entering the room, re-gloving, starting an exam): chin tuck, shoulders back, weight centered, exhale, then begin. The repetition is what builds the proprioceptive habit; eventually it fires without you thinking about it.
Stretch the tight, strengthen the weak
What procedural work does to most of us has a name: upper crossed syndrome, originally described by Janda. The pattern is recognizable — tight, overactive upper trapezius, levator scapulae, pectorals, sternocleidomastoid, and suboccipitals on one side; weak, inhibited deep cervical flexors, mid and lower trapezius, rhomboids, and serratus anterior on the other. The remedy mirrors the pattern: release and stretch the tight; build strength in the weak.
Building It Into the Day
None of the individual interventions take long. The reason they are hard to do consistently is not that they are difficult: it is that they are not ingrained during fellowship or practice. The exam rooms and ORs we work in are usually set up for the case, not for the surgeon. And the cost of ignoring ergonomics shows up not in a single moment but slowly, over time.
A daily rhythm helps. 5 to 10 minutes of mobility work before clinic and 15 minutes of strengthening afterwards. A standing posture reset between cases. A few discreet stretches that can be done while scrubbed in.
ErgoSherpa
I recently launched an ergonomics app to help other proceduralists: surgeons, dermatologists, dentists, oral surgeons, etc. There is ample literature about ergonomics, but none of it was housed in one convenient location with vetted routines and recommendations that could be easily digested. I combined videos of stretching and strengthening exercises with tips and tools for designing your workspace.
ErgoSherpa™ is a free wellness and ergonomics app for proceduralists of all stripes to help them avoid pain whether they are just starting out or decades into their careers. It is on the iOS App Store, and runs in any browser at ergosherpa.com for everyone else.
Ergonomics is what most of us were never taught, and there is no reason the next generation of proceduralists should have to learn it the hard way — from the slow accumulation of injury. In this case, an ounce of prevention is worth a pound of cure.
Disclaimer: This article is general ergonomic education and not medical advice. Consult your physician before starting a new exercise program or for persistent pain.
References
Liang CA, Levine VJ, Dusza SW, Hale EK, Nehal KS. Musculoskeletal disorders and ergonomics in dermatologic surgery: a survey of Mohs surgeons in 2010. Dermatol Surg. 2012;38(2):240–248.
Epstein S, Sparer EH, Tran BN, et al. Prevalence of Work-Related Musculoskeletal Disorders Among Surgeons and Interventionalists: A Systematic Review and Meta-analysis. JAMA Surg. 2018;153(2):e174947.