Increased reporting of musculoskeletal pain in anaesthetists: is it an occupational issue?

In this issue, an important paper by Leifer et al. describes an apparently high prevalence of musculoskeletal conditions from a survey of anaesthetists 1. The prevalence and type of upper limb disorders amongst anaesthetists and the associated risk factors were explored using an online survey and the study was based on self-reporting. Thirty-four per cent of those who answered the survey (n = 3884) reported they had a formal diagnosis of an upper limb disorder, with cervical disc prolapse/degeneration and rotator cuff tendinitis being the most common single diagnoses. Moreover, there were significant associations between reporting upper limb disorders and the number of years since starting anaesthetic training, having children (irrespective of the number of children) and being right-handed. The authors attributed the association found between upper limb disorders and the number of years since starting anaesthetic training and being right-handed with potential adverse ergonomic factors such as procedures involving awkward postures, especially during particular medical procedures including laryngoscopy, tracheal intubation, jugular venous cannulation and historical use of the Boyle's machine (designed by Boyle who was left-handed) 2. The authors postulated that the association of having children and developing upper limb disorders might be related to the additional lifting and carrying involved in parenthood. The study collected information on other potential aetiological factors such as sporting and hobby activities. There was less information on biopsychosocial factors which are well known to influence the prevalence of musculoskeletal conditions in working populations 3. Any study of musculoskeletal conditions at work needs to consider these other factors, particularly in relation to the biopsychosocial model of health 4, which can also contribute to this association and which were not measured in the paper. An example of this is the ‘double burden’, which is explained as the need to respond simultaneously to the demands of paid work outside home with raising children and unpaid domestic-family work 5. The biopsychosocial model of health was first proposed by Engel in 1997 4 and applied to musculoskeletal pain by Waddell in 1987 6. This has been the dominant framework in the conceptualisation of aetiology and prognosis of musculoskeletal pain. This model postulates that patients’ ill health is not exclusively a consequence of medical or biological issues; but behaviours, thoughts and feelings may also influence a physical state 7 and these factors need to be taken into account in aetiology. The survey questionnaire used in the study by Leifer et al. did not collect information about psychosocial and organisational aspects of work, such as their working hours, job demands, job satisfaction and individual psychological factors 3 which might contribute to a better understanding of the findings. In addition, the increasing burden of shift work and fatigue may be contributing factors which need to be further explored 8, 9. Work-related illness was estimated to affect 1.4 million people between 2017 and 2018, which represents 30.7 million working days lost due to work-related illness and workplace injuries 10. Doctors’ health and well-being has an important role in the optimum performance of healthcare systems. However, it has been observed that doctors have difficulties admitting to illness, sometimes self-manage their illnesses and they do not always behave like patients 11. In recent years, this tendency for the under-reporting of health issues in doctors has started to change. For example, it has been suggested that doctors’ attendance rates to occupational health have probably increased in the last few years 12 and it has been postulated that the increased demand on healthcare, heightening complexity of clinical practise and growing pressure on health professionals 13 might be leading doctors to report work-related conditions. Recently, the assessment of occupational health issues in doctors has attracted increased attention. A literature review identified 50 research papers about work-related conditions reported by doctors from the UK 14. Stress, burnout and mental health disorders were the leading causes, followed by substance abuse, sharps injuries and musculoskeletal conditions. Another review analysed the trends in NHS doctor and dentist referrals to occupational health over a 3-year period and found that mental health and musculoskeletal complaints we are the predominant referral reason for occupational health assessment 12. However, there is still a lack of information in the literature about the reporting of work-related disorders in larger specialities such as anaesthesia 14. Anaesthesia has classically been associated with exposure to ionising radiation 15 or inhalational anaesthetic agents 16, 17. With the general improvement in working conditions and the subsequent reduction in noxious exposures, much of the potential risk which can be attributed to physical and chemical hazards has been largely reduced. As a consequence, the focus of occupational health has moved to the health conditions which produce a substantial burden for health systems and a negative impact on workers’ well-being, but for which the causes cannot be exclusively attributed to work 18. Anaesthesia is not exempt from this trend and recent reports have started to emerge in the scientific literature of the effects of the exposure to stressors at the workplace, such as irregular and long working hours, the need to act quickly with vitally compromised patients 19 and the impact of awkward body postures on the development of musculoskeletal conditions 20. Findings such as those obtained in the paper performed by Leifer et al. reaffirm the usefulness and importance of good occupational health and safety in the healthcare workplace. Doctors are, in particular, a group of workers who take little sickness absence and are usually reluctant to access appropriate healthcare, often due to fears about confidentiality and self-stigmatising views 21. This interesting survey raises significant issues about the well-being at work of anaesthetists and is an important first step towards improving their working lives. Much further qualitative and quantitative research is required. This research should review the ergonomic demands of the tasks being undertaken in general across the speciality and identify work environments or equipment which may be associated with the development of discomfort and clinical conditions, with a view to elimination of hazardous tasks or improved ergonomics. The work of anaesthetists may involve over-exertion or cumulative over-use of musculoskeletal or other bodily structures, and the co-existence of psychologically stressful, tiring or emotionally demanding duties can all contribute to creating ill health. Such avoidable ill health is ultimately to the detriment of patients. Anaesthetists themselves will be best placed to inform the redesign of equipment or work places based on such work and in the interim, qualitative research using focus groups could be useful. The elimination where possible, of hazardous working postures in anaesthetics should be a priority for the profession and employers. No conflict of interest declared.