From Society of Gynecologic Surgeons

ILLUSTRATION: PAUL ZWOLAK

“If you don’t have a seat at the table, you are probably on the menu.” I first heard this quote in 2013, and it launched my interest in health care leadership and influenced me countless times over the last 10 years.

As Chief of Staff at Cleveland Clinic, I oversee nearly 5,000 physicians and scientists across the globe. I am involved in the physician life cycle: recruiting, hiring, privileging and credentialing, talent development, promotion, professionalism, and career transitions. I also sit at the intersection of medical care and the business of medicine. This means leading 18 clinical service lines responsible for 5.6 million visits, 161,000 surgeries, and billions of dollars in operating revenue per year. How I spend most of my time is a far cry from what I spent 11 years’ training to do—gynecologic surgery. This shift in my career was not because I changed my mind about caring for patients or that I tired of being a full-time surgeon. Nothing could be further from the truth. Women’s health remains my “why,” and my leadership journey has taught me that it is critical to have a seat at the table for the sake of ObGyns and women everywhere.

Women’s health on the menu

I will start with a concrete example of when we, as women and ObGyns, were on the menu. In late 2019, the Ohio state House of Representatives introduced a bill that subjected doctors to potential murder charges if they did not try everything to save the life of a mother and fetus, “including attempting to reimplant an ectopic pregnancy into the woman’s uterus.”¹ This bill was based on 2 case reports—one from 1915 and one from 1980—which were both low quality, and the latter case was deemed to be fraudulent.² How did this happen?

An Ohio state representative developed the bill with help from a lobbyist and without input from physicians or content experts. When asked, the representative shared that “he never researched whether re-implanting an ectopic pregnancy into a woman’s uterus was a viable medical procedure before including it in the bill.”³ He added, “I heard about it over the years. I never questioned it or gave it a lot of thought.”³

This example resonates deeply with many of us; it inspires us to speak up and act. As ObGyns, we clearly understand the consequences of legal and regulatory change in women’s health and how it directly impacts our patients and each of us as physicians. Let’s shift to something that you may feel less passion about, but I believe is equally important. This is where obstetrician-gynecologists sit in the intersection of medical care and business. This is the space where I spend most of my time, and from this vantage point, I worry about our field.

The business of medicine

Starting at the macroeconomic level, let’s think about how we as physicians are reimbursed and who makes these decisions. Looking at the national health care expenditure data, Medicare and Medicaid spending makes up nearly 40% of the total spend, and it is growing.⁴ Additionally, private health insurance tends to follow Centers for Medicare and Medicaid Services (CMS) decision making, further compounding its influence.⁴ In simple terms, CMS decides what is covered and how much we are paid. Whether you are in a solo private practice, an employer health care organization, or an academic medical center, physician reimbursement is declining.

In fact, Congress passed its year-end omnibus legislation in the final days of 2022, including a 2% Medicare physician payment cut for 2023,⁵ at a time when expenses to practice medicine, including nonphysician staff and supplies, are at an all-time high and we are living in a 6% inflationary state. This translates into being asked to serve more patients and cut costs. Our day-to-day feels much tighter, and this is why: Medicare physician pay increased just 11% over the past 20 years⁶ (2001–2021) in comparison to the cost of running a medical practice, which increased nearly 40% during that time. In other words, adjusting for inflation in practice costs, Medicare physician payment has fallen 22% over the last 20 years.⁷

Depending on your employment model, you may feel insulated from these changes as increases in reimbursement have occurred in other areas, such as hospitals and ambulatory surgery centers.⁸ In the short term, these increases help, as organizations will see additional funds. But there are 2 main issues: First, it is not nearly enough when you consider the soaring costs of running a hospital. And second, looking at our national population, we rely tremendously on self-employed doctors to serve our patients.

More than 80% of US counties lack adequate health care infrastructure.⁹ More than a third of the US population has less-than-adequate access to pharmacies, primary care physicians, hospitals, trauma centers, and low-cost health centers.⁹ To put things into perspective, more than 20% of counties in the United States are hospital deserts, where most people must drive more than 30 minutes to reach the closest hospital.⁹

There is good reason for this. Operating a hospital is a challenging endeavor. Even before the COVID-19 pandemic and the most recent health care financial challenges, most health care systems and large hospitals operated with very low operating margins (2%–3%). Businesses with similar margins include grocery stores and car dealerships. These low-margin businesses, including health care, rely on high volume for sustainability. High patient volumes distribute expensive hospital costs over many encounters. If physicians cannot sustain practices across the country, it is challenging to have sufficient admission and surgical volumes to justify the cost base of hospitals.

To tie this together, we have very little influence on what we are paid for our services. Reimbursement is declining, which makes it hard to have financially sustainable practices. As hospitals struggle, there is more pressure to prioritize highly profitable service lines, like orthopedics and urology, which are associated with favorable technical revenue. As hospitals are threatened, health care deserts widen, which leaves our entire health care system in jeopardy. Not surprisingly, this most likely affects those who face additional barriers to access, such as those with lower income, limited internet access, and lack of insurance. Together, these barriers further widen disparities in health care outcomes, including outcomes for women. Additionally, this death by a thousand cuts has eroded morale and increased physician burnout.

Transforming how we practice medicine is the only viable solution. I have good news: You are the leaders you have been waiting for.

Continue to: Physicians make good managers...

Physicians make good managers

To successfully transform how we practice medicine, it is critical that those leading the transformation deeply understand how medicine is practiced. The level of understanding required can be achieved only through years of medical practice, as a doctor. We understand how medical teams interact and that different sectors of our health care system are interdependent. Also, because physicians drive patient activity and ultimately reimbursement, having a seat at the table is crucial.

Some health care systems are run by businesspeople—people with finance backgrounds—and others are led by physicians. In 2017, Becker’s Hospital Review listed the chief executive officers (CEOs) of 183 nonprofit hospital and health systems.¹⁰ Of these, only 25% were led by individuals with an MD. Looking at the 115 largest hospitals in the United States, 30% are physician led.¹⁰ Considering the top 10 hospitals ranked by U.S. News & World Report for 2022, 8 of 10 have a physician at the helm.

Beyond raters and rankers, physician-led hospitals do better. Goodall compared CEOs in the top 100 best hospitals in U.S. News & World Report in 3 key medical specialties: cancer, digestive disorders, and cardiac care.¹¹ The study explored the question: “Are hospitals’ quality ranked more highly when they are led by a medically trained doctor or non-MD professional managers?”¹¹ Analysis revealed that hospital quality scores are about 25% higher in physician-run hospitals than in manager-run hospitals.¹¹ Additional research shows that good management practices correlate with hospital performance, and that “the proportion of managers with a clinical degree has the largest positive effect.”¹²

Several theories exist as to why doctors make good managers in the health care setting.^13,14 Doctors may create a more sympathetic and productive work environment for other clinicians because they are one of them. They have peer-to-peer credibility—because they have walked the walk, they have insight and perspective into how medicine is practiced.

Physicians serve as effective change agents for their organizations in several ways:

• First, physicians take a clinical approach in their leadership roles¹³ and focus on patient care at the center of their decisions. We see the people behind the numbers. Simply put, we humanize the operational side of health care.
• As physicians, we understand the interconnectivity in the practice of medicine. While closing certain service lines may be financially beneficial, these services are often closely linked to profitable service lines.
• Beyond physicians taking a clinical approach to leadership, we emphasize quality.¹³ Because we all have experienced complications and lived through bad outcomes alongside our patients, we understand deeply how important patient safety and quality is, and we are not willing to sacrifice that for financial gain. For us, this is personal. We don’t see our solution to health care challenges as an “or” situation, instead we view it as an “and” situation.
• Physician leaders often can improve medical staff engagement.¹³ A 2018 national survey of physicians found that those who are satisfied with their leadership are more engaged at work, have greater job satisfaction, and are less likely to experience signs of burnout.¹⁵ Physician administrators add value here.

Continue to: Surgeons as leaders...

Surgeons as leaders

What do we know about surgeons as physician leaders? Looking at the previously mentioned lists of physician leaders, surgeons are relatively absent. In the Becker’s Hospital Review study of nonprofit hospitals, only 9% of CEOs were surgeons.¹⁰ In addition, when reviewing data that associated physician leaders and hospital performance, only 3 of the CEOs were surgeons.¹¹ Given that surgeons make up approximately 19% of US physicians, we are underrepresented.

The omission of surgeons as leaders seems inappropriate given that most hospitals are financially reliant on revenue related to surgical care and optimizing this space is an enormous opportunity. Berger and colleagues offered 3 theories as to why there are fewer surgeon leaders¹⁶:

• The relative pay of surgeons exceeds that of most other specialties, and there may be less incentive to accept the challenges presented by leadership roles. (I will add that surgeon leadership is more costly to a system.)
• The craftsmanship nature of surgery discourages the development of other career interests beginning at the trainee level.
• Surgeons have been perceived stereotypically to exhibit arrogance, a characteristic that others may not warm to.

This last observation stings. Successful leadership takes social skill and teamwork.¹⁴ Although medical care is one of the few disciplines in which lack of teamwork might cost lives, physicians are not trained to be team players. We recognize how our training has led us to be lone wolves or gunners, situations where we as individuals had to beat others to secure our spot. We have been trained in command-and-control environments, in stepping up as a leader in highly stressful situations. This part of surgical culture may handicap surgeons in their quest to be health care leaders.

Other traits, however, make us particularly great leaders in health care. Our desire to succeed, willingness to push ourselves to extremes, ability to laser focus on a task, acceptance of delayed gratification, and aptitude for making timely decisions on limited data help us succeed in leadership roles. Seven years of surgical training helped me develop the grit I use every day in the C-suite.

We need more physician and surgeon leadership to thrive in the challenging health care landscape. Berger and colleagues proposed 3 potential solutions to increase the number of surgeons in hospital leadership positions¹⁶:

Nurture future surgical leaders through exposure to management training. Given the contribution to both expense in support services and resources and revenue related to surgical care, each organization needs a content expert to guide these decisions.

Recognize the important contributions that surgeons already make regarding quality, safety, and operational efficiency. An excellent example of this is the American College of Surgeons National Surgical Quality Improvement Program. Because surgeons are content experts in this area, we are primed to lead.

Hospitals, medical schools, and academic departments of surgery should recognize administrative efforts as an important part of the overall academic mission. As the adage states, “No margin, no mission.” We need bright minds to preserve and grow our margins so that we can further invest in our missions.

This is not easy. Given the barriers, this will not happen organically. Charan and colleagues provided an outline for a leadership pathway adapted for physicians (FIGURE).^17,18 It starts with the individual practitioner who is a practicing physician and spends most of their time focused on patient care. As a physician becomes more interested in leadership, they develop new skills and take on more and more responsibility. As they increase in leadership responsibility, they tend to reduce clinical time and increase time spent on strategic and business management. This framework creates a pipeline so that physicians and surgeons can be developed strategically and given increasing responsibility as they develop their capabilities and expand their skill sets.

The leadership challenge

To thrive, we must transform health care by changing how we practice medicine. As ObGyns, we are the leaders we have been waiting for. As you ponder your future, think of your current career and the opportunities you might have. Do you have a seat at the table? What table is that? How are you using your knowledge, expertise, and privilege to advance health care and medicine? I challenge you to critically evaluate this—and lead. ●

ILLUSTRATION: PAUL ZWOLAK

“If you don’t have a seat at the table, you are probably on the menu.” I first heard this quote in 2013, and it launched my interest in health care leadership and influenced me countless times over the last 10 years.

As Chief of Staff at Cleveland Clinic, I oversee nearly 5,000 physicians and scientists across the globe. I am involved in the physician life cycle: recruiting, hiring, privileging and credentialing, talent development, promotion, professionalism, and career transitions. I also sit at the intersection of medical care and the business of medicine. This means leading 18 clinical service lines responsible for 5.6 million visits, 161,000 surgeries, and billions of dollars in operating revenue per year. How I spend most of my time is a far cry from what I spent 11 years’ training to do—gynecologic surgery. This shift in my career was not because I changed my mind about caring for patients or that I tired of being a full-time surgeon. Nothing could be further from the truth. Women’s health remains my “why,” and my leadership journey has taught me that it is critical to have a seat at the table for the sake of ObGyns and women everywhere.

Women’s health on the menu

I will start with a concrete example of when we, as women and ObGyns, were on the menu. In late 2019, the Ohio state House of Representatives introduced a bill that subjected doctors to potential murder charges if they did not try everything to save the life of a mother and fetus, “including attempting to reimplant an ectopic pregnancy into the woman’s uterus.”¹ This bill was based on 2 case reports—one from 1915 and one from 1980—which were both low quality, and the latter case was deemed to be fraudulent.² How did this happen?

An Ohio state representative developed the bill with help from a lobbyist and without input from physicians or content experts. When asked, the representative shared that “he never researched whether re-implanting an ectopic pregnancy into a woman’s uterus was a viable medical procedure before including it in the bill.”³ He added, “I heard about it over the years. I never questioned it or gave it a lot of thought.”³

This example resonates deeply with many of us; it inspires us to speak up and act. As ObGyns, we clearly understand the consequences of legal and regulatory change in women’s health and how it directly impacts our patients and each of us as physicians. Let’s shift to something that you may feel less passion about, but I believe is equally important. This is where obstetrician-gynecologists sit in the intersection of medical care and business. This is the space where I spend most of my time, and from this vantage point, I worry about our field.

The business of medicine

Starting at the macroeconomic level, let’s think about how we as physicians are reimbursed and who makes these decisions. Looking at the national health care expenditure data, Medicare and Medicaid spending makes up nearly 40% of the total spend, and it is growing.⁴ Additionally, private health insurance tends to follow Centers for Medicare and Medicaid Services (CMS) decision making, further compounding its influence.⁴ In simple terms, CMS decides what is covered and how much we are paid. Whether you are in a solo private practice, an employer health care organization, or an academic medical center, physician reimbursement is declining.

In fact, Congress passed its year-end omnibus legislation in the final days of 2022, including a 2% Medicare physician payment cut for 2023,⁵ at a time when expenses to practice medicine, including nonphysician staff and supplies, are at an all-time high and we are living in a 6% inflationary state. This translates into being asked to serve more patients and cut costs. Our day-to-day feels much tighter, and this is why: Medicare physician pay increased just 11% over the past 20 years⁶ (2001–2021) in comparison to the cost of running a medical practice, which increased nearly 40% during that time. In other words, adjusting for inflation in practice costs, Medicare physician payment has fallen 22% over the last 20 years.⁷

Depending on your employment model, you may feel insulated from these changes as increases in reimbursement have occurred in other areas, such as hospitals and ambulatory surgery centers.⁸ In the short term, these increases help, as organizations will see additional funds. But there are 2 main issues: First, it is not nearly enough when you consider the soaring costs of running a hospital. And second, looking at our national population, we rely tremendously on self-employed doctors to serve our patients.

More than 80% of US counties lack adequate health care infrastructure.⁹ More than a third of the US population has less-than-adequate access to pharmacies, primary care physicians, hospitals, trauma centers, and low-cost health centers.⁹ To put things into perspective, more than 20% of counties in the United States are hospital deserts, where most people must drive more than 30 minutes to reach the closest hospital.⁹

There is good reason for this. Operating a hospital is a challenging endeavor. Even before the COVID-19 pandemic and the most recent health care financial challenges, most health care systems and large hospitals operated with very low operating margins (2%–3%). Businesses with similar margins include grocery stores and car dealerships. These low-margin businesses, including health care, rely on high volume for sustainability. High patient volumes distribute expensive hospital costs over many encounters. If physicians cannot sustain practices across the country, it is challenging to have sufficient admission and surgical volumes to justify the cost base of hospitals.

To tie this together, we have very little influence on what we are paid for our services. Reimbursement is declining, which makes it hard to have financially sustainable practices. As hospitals struggle, there is more pressure to prioritize highly profitable service lines, like orthopedics and urology, which are associated with favorable technical revenue. As hospitals are threatened, health care deserts widen, which leaves our entire health care system in jeopardy. Not surprisingly, this most likely affects those who face additional barriers to access, such as those with lower income, limited internet access, and lack of insurance. Together, these barriers further widen disparities in health care outcomes, including outcomes for women. Additionally, this death by a thousand cuts has eroded morale and increased physician burnout.

Transforming how we practice medicine is the only viable solution. I have good news: You are the leaders you have been waiting for.

Continue to: Physicians make good managers...

Physicians make good managers

To successfully transform how we practice medicine, it is critical that those leading the transformation deeply understand how medicine is practiced. The level of understanding required can be achieved only through years of medical practice, as a doctor. We understand how medical teams interact and that different sectors of our health care system are interdependent. Also, because physicians drive patient activity and ultimately reimbursement, having a seat at the table is crucial.

Some health care systems are run by businesspeople—people with finance backgrounds—and others are led by physicians. In 2017, Becker’s Hospital Review listed the chief executive officers (CEOs) of 183 nonprofit hospital and health systems.¹⁰ Of these, only 25% were led by individuals with an MD. Looking at the 115 largest hospitals in the United States, 30% are physician led.¹⁰ Considering the top 10 hospitals ranked by U.S. News & World Report for 2022, 8 of 10 have a physician at the helm.

Beyond raters and rankers, physician-led hospitals do better. Goodall compared CEOs in the top 100 best hospitals in U.S. News & World Report in 3 key medical specialties: cancer, digestive disorders, and cardiac care.¹¹ The study explored the question: “Are hospitals’ quality ranked more highly when they are led by a medically trained doctor or non-MD professional managers?”¹¹ Analysis revealed that hospital quality scores are about 25% higher in physician-run hospitals than in manager-run hospitals.¹¹ Additional research shows that good management practices correlate with hospital performance, and that “the proportion of managers with a clinical degree has the largest positive effect.”¹²

Several theories exist as to why doctors make good managers in the health care setting.^13,14 Doctors may create a more sympathetic and productive work environment for other clinicians because they are one of them. They have peer-to-peer credibility—because they have walked the walk, they have insight and perspective into how medicine is practiced.

Physicians serve as effective change agents for their organizations in several ways:

• First, physicians take a clinical approach in their leadership roles¹³ and focus on patient care at the center of their decisions. We see the people behind the numbers. Simply put, we humanize the operational side of health care.
• As physicians, we understand the interconnectivity in the practice of medicine. While closing certain service lines may be financially beneficial, these services are often closely linked to profitable service lines.
• Beyond physicians taking a clinical approach to leadership, we emphasize quality.¹³ Because we all have experienced complications and lived through bad outcomes alongside our patients, we understand deeply how important patient safety and quality is, and we are not willing to sacrifice that for financial gain. For us, this is personal. We don’t see our solution to health care challenges as an “or” situation, instead we view it as an “and” situation.
• Physician leaders often can improve medical staff engagement.¹³ A 2018 national survey of physicians found that those who are satisfied with their leadership are more engaged at work, have greater job satisfaction, and are less likely to experience signs of burnout.¹⁵ Physician administrators add value here.

Continue to: Surgeons as leaders...

Surgeons as leaders

What do we know about surgeons as physician leaders? Looking at the previously mentioned lists of physician leaders, surgeons are relatively absent. In the Becker’s Hospital Review study of nonprofit hospitals, only 9% of CEOs were surgeons.¹⁰ In addition, when reviewing data that associated physician leaders and hospital performance, only 3 of the CEOs were surgeons.¹¹ Given that surgeons make up approximately 19% of US physicians, we are underrepresented.

The omission of surgeons as leaders seems inappropriate given that most hospitals are financially reliant on revenue related to surgical care and optimizing this space is an enormous opportunity. Berger and colleagues offered 3 theories as to why there are fewer surgeon leaders¹⁶:

• The relative pay of surgeons exceeds that of most other specialties, and there may be less incentive to accept the challenges presented by leadership roles. (I will add that surgeon leadership is more costly to a system.)
• The craftsmanship nature of surgery discourages the development of other career interests beginning at the trainee level.
• Surgeons have been perceived stereotypically to exhibit arrogance, a characteristic that others may not warm to.

This last observation stings. Successful leadership takes social skill and teamwork.¹⁴ Although medical care is one of the few disciplines in which lack of teamwork might cost lives, physicians are not trained to be team players. We recognize how our training has led us to be lone wolves or gunners, situations where we as individuals had to beat others to secure our spot. We have been trained in command-and-control environments, in stepping up as a leader in highly stressful situations. This part of surgical culture may handicap surgeons in their quest to be health care leaders.

Other traits, however, make us particularly great leaders in health care. Our desire to succeed, willingness to push ourselves to extremes, ability to laser focus on a task, acceptance of delayed gratification, and aptitude for making timely decisions on limited data help us succeed in leadership roles. Seven years of surgical training helped me develop the grit I use every day in the C-suite.

We need more physician and surgeon leadership to thrive in the challenging health care landscape. Berger and colleagues proposed 3 potential solutions to increase the number of surgeons in hospital leadership positions¹⁶:

Nurture future surgical leaders through exposure to management training. Given the contribution to both expense in support services and resources and revenue related to surgical care, each organization needs a content expert to guide these decisions.

Recognize the important contributions that surgeons already make regarding quality, safety, and operational efficiency. An excellent example of this is the American College of Surgeons National Surgical Quality Improvement Program. Because surgeons are content experts in this area, we are primed to lead.

Hospitals, medical schools, and academic departments of surgery should recognize administrative efforts as an important part of the overall academic mission. As the adage states, “No margin, no mission.” We need bright minds to preserve and grow our margins so that we can further invest in our missions.

This is not easy. Given the barriers, this will not happen organically. Charan and colleagues provided an outline for a leadership pathway adapted for physicians (FIGURE).^17,18 It starts with the individual practitioner who is a practicing physician and spends most of their time focused on patient care. As a physician becomes more interested in leadership, they develop new skills and take on more and more responsibility. As they increase in leadership responsibility, they tend to reduce clinical time and increase time spent on strategic and business management. This framework creates a pipeline so that physicians and surgeons can be developed strategically and given increasing responsibility as they develop their capabilities and expand their skill sets.

The leadership challenge

To thrive, we must transform health care by changing how we practice medicine. As ObGyns, we are the leaders we have been waiting for. As you ponder your future, think of your current career and the opportunities you might have. Do you have a seat at the table? What table is that? How are you using your knowledge, expertise, and privilege to advance health care and medicine? I challenge you to critically evaluate this—and lead. ●

ILLUSTRATION: PAUL ZWOLAK

“If you don’t have a seat at the table, you are probably on the menu.” I first heard this quote in 2013, and it launched my interest in health care leadership and influenced me countless times over the last 10 years.

As Chief of Staff at Cleveland Clinic, I oversee nearly 5,000 physicians and scientists across the globe. I am involved in the physician life cycle: recruiting, hiring, privileging and credentialing, talent development, promotion, professionalism, and career transitions. I also sit at the intersection of medical care and the business of medicine. This means leading 18 clinical service lines responsible for 5.6 million visits, 161,000 surgeries, and billions of dollars in operating revenue per year. How I spend most of my time is a far cry from what I spent 11 years’ training to do—gynecologic surgery. This shift in my career was not because I changed my mind about caring for patients or that I tired of being a full-time surgeon. Nothing could be further from the truth. Women’s health remains my “why,” and my leadership journey has taught me that it is critical to have a seat at the table for the sake of ObGyns and women everywhere.

Women’s health on the menu

I will start with a concrete example of when we, as women and ObGyns, were on the menu. In late 2019, the Ohio state House of Representatives introduced a bill that subjected doctors to potential murder charges if they did not try everything to save the life of a mother and fetus, “including attempting to reimplant an ectopic pregnancy into the woman’s uterus.”¹ This bill was based on 2 case reports—one from 1915 and one from 1980—which were both low quality, and the latter case was deemed to be fraudulent.² How did this happen?

An Ohio state representative developed the bill with help from a lobbyist and without input from physicians or content experts. When asked, the representative shared that “he never researched whether re-implanting an ectopic pregnancy into a woman’s uterus was a viable medical procedure before including it in the bill.”³ He added, “I heard about it over the years. I never questioned it or gave it a lot of thought.”³

This example resonates deeply with many of us; it inspires us to speak up and act. As ObGyns, we clearly understand the consequences of legal and regulatory change in women’s health and how it directly impacts our patients and each of us as physicians. Let’s shift to something that you may feel less passion about, but I believe is equally important. This is where obstetrician-gynecologists sit in the intersection of medical care and business. This is the space where I spend most of my time, and from this vantage point, I worry about our field.

The business of medicine

Starting at the macroeconomic level, let’s think about how we as physicians are reimbursed and who makes these decisions. Looking at the national health care expenditure data, Medicare and Medicaid spending makes up nearly 40% of the total spend, and it is growing.⁴ Additionally, private health insurance tends to follow Centers for Medicare and Medicaid Services (CMS) decision making, further compounding its influence.⁴ In simple terms, CMS decides what is covered and how much we are paid. Whether you are in a solo private practice, an employer health care organization, or an academic medical center, physician reimbursement is declining.

In fact, Congress passed its year-end omnibus legislation in the final days of 2022, including a 2% Medicare physician payment cut for 2023,⁵ at a time when expenses to practice medicine, including nonphysician staff and supplies, are at an all-time high and we are living in a 6% inflationary state. This translates into being asked to serve more patients and cut costs. Our day-to-day feels much tighter, and this is why: Medicare physician pay increased just 11% over the past 20 years⁶ (2001–2021) in comparison to the cost of running a medical practice, which increased nearly 40% during that time. In other words, adjusting for inflation in practice costs, Medicare physician payment has fallen 22% over the last 20 years.⁷

Depending on your employment model, you may feel insulated from these changes as increases in reimbursement have occurred in other areas, such as hospitals and ambulatory surgery centers.⁸ In the short term, these increases help, as organizations will see additional funds. But there are 2 main issues: First, it is not nearly enough when you consider the soaring costs of running a hospital. And second, looking at our national population, we rely tremendously on self-employed doctors to serve our patients.

More than 80% of US counties lack adequate health care infrastructure.⁹ More than a third of the US population has less-than-adequate access to pharmacies, primary care physicians, hospitals, trauma centers, and low-cost health centers.⁹ To put things into perspective, more than 20% of counties in the United States are hospital deserts, where most people must drive more than 30 minutes to reach the closest hospital.⁹

There is good reason for this. Operating a hospital is a challenging endeavor. Even before the COVID-19 pandemic and the most recent health care financial challenges, most health care systems and large hospitals operated with very low operating margins (2%–3%). Businesses with similar margins include grocery stores and car dealerships. These low-margin businesses, including health care, rely on high volume for sustainability. High patient volumes distribute expensive hospital costs over many encounters. If physicians cannot sustain practices across the country, it is challenging to have sufficient admission and surgical volumes to justify the cost base of hospitals.

To tie this together, we have very little influence on what we are paid for our services. Reimbursement is declining, which makes it hard to have financially sustainable practices. As hospitals struggle, there is more pressure to prioritize highly profitable service lines, like orthopedics and urology, which are associated with favorable technical revenue. As hospitals are threatened, health care deserts widen, which leaves our entire health care system in jeopardy. Not surprisingly, this most likely affects those who face additional barriers to access, such as those with lower income, limited internet access, and lack of insurance. Together, these barriers further widen disparities in health care outcomes, including outcomes for women. Additionally, this death by a thousand cuts has eroded morale and increased physician burnout.

Transforming how we practice medicine is the only viable solution. I have good news: You are the leaders you have been waiting for.

Continue to: Physicians make good managers...

Physicians make good managers

To successfully transform how we practice medicine, it is critical that those leading the transformation deeply understand how medicine is practiced. The level of understanding required can be achieved only through years of medical practice, as a doctor. We understand how medical teams interact and that different sectors of our health care system are interdependent. Also, because physicians drive patient activity and ultimately reimbursement, having a seat at the table is crucial.

Some health care systems are run by businesspeople—people with finance backgrounds—and others are led by physicians. In 2017, Becker’s Hospital Review listed the chief executive officers (CEOs) of 183 nonprofit hospital and health systems.¹⁰ Of these, only 25% were led by individuals with an MD. Looking at the 115 largest hospitals in the United States, 30% are physician led.¹⁰ Considering the top 10 hospitals ranked by U.S. News & World Report for 2022, 8 of 10 have a physician at the helm.

Beyond raters and rankers, physician-led hospitals do better. Goodall compared CEOs in the top 100 best hospitals in U.S. News & World Report in 3 key medical specialties: cancer, digestive disorders, and cardiac care.¹¹ The study explored the question: “Are hospitals’ quality ranked more highly when they are led by a medically trained doctor or non-MD professional managers?”¹¹ Analysis revealed that hospital quality scores are about 25% higher in physician-run hospitals than in manager-run hospitals.¹¹ Additional research shows that good management practices correlate with hospital performance, and that “the proportion of managers with a clinical degree has the largest positive effect.”¹²

Several theories exist as to why doctors make good managers in the health care setting.^13,14 Doctors may create a more sympathetic and productive work environment for other clinicians because they are one of them. They have peer-to-peer credibility—because they have walked the walk, they have insight and perspective into how medicine is practiced.

Physicians serve as effective change agents for their organizations in several ways:

• First, physicians take a clinical approach in their leadership roles¹³ and focus on patient care at the center of their decisions. We see the people behind the numbers. Simply put, we humanize the operational side of health care.
• As physicians, we understand the interconnectivity in the practice of medicine. While closing certain service lines may be financially beneficial, these services are often closely linked to profitable service lines.
• Beyond physicians taking a clinical approach to leadership, we emphasize quality.¹³ Because we all have experienced complications and lived through bad outcomes alongside our patients, we understand deeply how important patient safety and quality is, and we are not willing to sacrifice that for financial gain. For us, this is personal. We don’t see our solution to health care challenges as an “or” situation, instead we view it as an “and” situation.
• Physician leaders often can improve medical staff engagement.¹³ A 2018 national survey of physicians found that those who are satisfied with their leadership are more engaged at work, have greater job satisfaction, and are less likely to experience signs of burnout.¹⁵ Physician administrators add value here.

Continue to: Surgeons as leaders...

Surgeons as leaders

What do we know about surgeons as physician leaders? Looking at the previously mentioned lists of physician leaders, surgeons are relatively absent. In the Becker’s Hospital Review study of nonprofit hospitals, only 9% of CEOs were surgeons.¹⁰ In addition, when reviewing data that associated physician leaders and hospital performance, only 3 of the CEOs were surgeons.¹¹ Given that surgeons make up approximately 19% of US physicians, we are underrepresented.

The omission of surgeons as leaders seems inappropriate given that most hospitals are financially reliant on revenue related to surgical care and optimizing this space is an enormous opportunity. Berger and colleagues offered 3 theories as to why there are fewer surgeon leaders¹⁶:

• The relative pay of surgeons exceeds that of most other specialties, and there may be less incentive to accept the challenges presented by leadership roles. (I will add that surgeon leadership is more costly to a system.)
• The craftsmanship nature of surgery discourages the development of other career interests beginning at the trainee level.
• Surgeons have been perceived stereotypically to exhibit arrogance, a characteristic that others may not warm to.

This last observation stings. Successful leadership takes social skill and teamwork.¹⁴ Although medical care is one of the few disciplines in which lack of teamwork might cost lives, physicians are not trained to be team players. We recognize how our training has led us to be lone wolves or gunners, situations where we as individuals had to beat others to secure our spot. We have been trained in command-and-control environments, in stepping up as a leader in highly stressful situations. This part of surgical culture may handicap surgeons in their quest to be health care leaders.

Other traits, however, make us particularly great leaders in health care. Our desire to succeed, willingness to push ourselves to extremes, ability to laser focus on a task, acceptance of delayed gratification, and aptitude for making timely decisions on limited data help us succeed in leadership roles. Seven years of surgical training helped me develop the grit I use every day in the C-suite.

We need more physician and surgeon leadership to thrive in the challenging health care landscape. Berger and colleagues proposed 3 potential solutions to increase the number of surgeons in hospital leadership positions¹⁶:

Nurture future surgical leaders through exposure to management training. Given the contribution to both expense in support services and resources and revenue related to surgical care, each organization needs a content expert to guide these decisions.

Recognize the important contributions that surgeons already make regarding quality, safety, and operational efficiency. An excellent example of this is the American College of Surgeons National Surgical Quality Improvement Program. Because surgeons are content experts in this area, we are primed to lead.

Hospitals, medical schools, and academic departments of surgery should recognize administrative efforts as an important part of the overall academic mission. As the adage states, “No margin, no mission.” We need bright minds to preserve and grow our margins so that we can further invest in our missions.

This is not easy. Given the barriers, this will not happen organically. Charan and colleagues provided an outline for a leadership pathway adapted for physicians (FIGURE).^17,18 It starts with the individual practitioner who is a practicing physician and spends most of their time focused on patient care. As a physician becomes more interested in leadership, they develop new skills and take on more and more responsibility. As they increase in leadership responsibility, they tend to reduce clinical time and increase time spent on strategic and business management. This framework creates a pipeline so that physicians and surgeons can be developed strategically and given increasing responsibility as they develop their capabilities and expand their skill sets.

The leadership challenge

To thrive, we must transform health care by changing how we practice medicine. As ObGyns, we are the leaders we have been waiting for. As you ponder your future, think of your current career and the opportunities you might have. Do you have a seat at the table? What table is that? How are you using your knowledge, expertise, and privilege to advance health care and medicine? I challenge you to critically evaluate this—and lead. ●

Over the last 3 decades, abundant evidence has demonstrated the association between surgical volume and outcomes. Patients operated on by high-volume surgeons and at high-volume hospitals have superior outcomes.^1,2 This relationship has provided a framework for a number of public health policies to try to align patients with appropriate providers and centers to optimize perioperative outcomes. In this article, we examine the volume-outcomes paradigm for gynecologic surgery and explore how this relationship is influencing patterns of care and policy.

Surgical volume in gynecology

The association between both hospital and surgeon volume and outcomes has been explored across a number of gynecologic procedures.³ A meta-analysis that included 741,000 patients found that low-volume surgeons had an increased rate of complications overall, a higher rate of intraoperative complications, and a higher rate of postoperative complications compared with high-volume surgeons. While there was no association between volume and mortality overall, when limited to gynecologic oncology studies, low surgeon volume was associated with increased perioperative mortality.³

While these studies demonstrated a statistically significant association between surgeon volume and perioperative outcomes, the magnitude of the effect is modest compared with other higher-risk procedures associated with greater perioperative morbidity. For example, in a large study that examined oncologic and cardiovascular surgery, perioperative mortality in patients who underwent pancreatic resection was reduced from 15% for low-volume surgeons to 5% for high-volume surgeons.¹ By contrast, for gynecologic surgery, complications occurred in 97 per 1,000 patients operated on by high-volume surgeons compared with between 114 and 137 per 1,000 for low-volume surgeons. Thus, to avoid 1 in-hospital complication, 30 surgeries performed by low-volume surgeons would need to be moved to high-volume surgeons. For intraoperative complications, 38 patients would need to be moved from low- to high-volume surgeons to prevent 1 such complication.³ In addition to morbidity and mortality, higher surgeon volume is associated with greater use of minimally invasive surgery, a lower likelihood of conversion to laparotomy, and lower costs.³

Continue to: Public health applications of gynecologic surgical volume...

Public health applications of gynecologic surgical volume

The large body of literature on volume and outcomes has led to a number of public health initiatives aimed at reducing perioperative morbidity and mortality. Broadly, these efforts focus on regionalization of care, targeted quality improvement, and the development of minimum volume standards. Each strategy holds promise but also the potential to lead to unwanted consequences.

Regionalization of care

Recognition of the volume-outcomes paradigm has led to efforts to regionalize care for complex procedures to high-volume surgeons and centers.¹⁰ A cohort study of surgical patterns of care for Medicare recipients who underwent cancer resections or abdominal aortic aneurysm repair from 1999 to 2008 demonstrated these shifting practice patterns. For example, in 1999–2000, pancreatectomy was performed in 1,308 hospitals, with a median case volume of 5 procedures per year. By 2007–2008, the number of hospitals in which pancreatectomy was performed declined to 978, and the median case volume rose to 16 procedures per year. Importantly, over this time period, risk-adjusted mortality for pancreatectomy declined by 19%, and increased hospital volume was responsible for more than two-thirds of the decline in mortality.¹⁰

There has similarly been a gradual concentration of some gynecologic procedures to higher-volume surgeons and centers.^11,12 Among patients undergoing hysterectomy for endometrial cancer in New York State, 845 surgeons with a mean case volume of 3 procedures per year treated patients in 2000. By 2014, the number of surgeons who performed these operations declined to 317 while mean annual case volume rose to 10 procedures per year. The number of hospitals in which women with endometrial cancer were treated declined from 182 to 98 over the same time period.¹¹ Similar trends were noted for patients undergoing ovarian cancer resection.¹² While patterns of gynecologic care for some surgical procedures have clearly changed, it has been more difficult to link these changes to improvements in outcomes.^11,12

Despite the intuitive appeal of regionalization of surgical care, such a strategy has a number of limitations and practical challenges. Not surprisingly, limiting the number of surgeons and hospitals that perform a given procedure necessitates that patients travel a greater distance to obtain necessary surgical care.^13,14 An analysis of endometrial cancer patients in New York State stratified patients based on their area of residence into 10 hospital referral regions (HRRs), which represent health care markets for tertiary medical care. From 2000 to 2014, the distance patients traveled to receive their surgical care increased in all of the HRRs studied. This was most pronounced in 1 of the HRRs in which the median travel distance rose by 47 miles over the 15-year period (FIGURE 1; FIGURE 2).¹⁴

Whether patients are willing to travel for care remains a matter of debate and depends on the disease, the surgical procedure, and the anticipated benefit associated with a longer travel distance.^15,16 In a discrete choice experiment, 100 participants were given a hypothetical scenario in which they had potentially resectable pancreatic cancer; they were queried on their willingness to travel for care based on varying differences in mortality between a local and regional hospital.¹⁵ When mortality at the local hospital was double that of the regional hospital (6% vs 3%), 45% of patients chose to remain at the local hospital. When the differential increased to a 4 times greater mortality at the local hospital (12% vs 3%), 23% of patients still chose to remain at the local hospital.¹⁵

Lastly, a number of studies have shown that regionalization of surgical care disproportionately affects Black and Hispanic patients and those with low socioeconomic status.^12,13,17 A simulation study on the effect of regionalizing care for pancreatectomy noted that using a hospital volume threshold of 20 procedures per year, a higher percentage of Black and Hispanic patients than White patients would be required to travel to a higher-volume center.¹³ Similarly, Medicaid recipients were more likely to be affected.¹³ Despite the inequities in who must travel for regionalized care, prior work has suggested that regionalization of cancer care to high-volume centers may reduce racial and socioeconomic disparities in survival for some cancers.¹⁸

Targeted quality improvement

Realizing the practical limitations of regionalization of care, an alternative strategy is to improve the quality of care at low-volume hospitals.^5,19 Quality of care and surgical volume often are correlated, and the delivery of high-quality care can mitigate some of the influence of surgical volume on outcomes.

These principles were demonstrated in a study of more than 100,000 patients with ovarian cancer that stratified treating hospitals into volume quintiles.⁵ As expected, survival (both 2- and 5-year) was highest in the highest-volume quintile hospitals (FIGURE 3).⁵ Similarly, quality of care, measured through adherence to various process measures, was also highest in the highest-volume quintile hospitals. Interestingly, in the second-fourth volume quintile hospitals, there was substantial variation in adherence to quality metrics. Among hospitals with higher quality care, an improved survival was noted compared with lower quality care hospitals within the same volume quintile. Survival at high-quality, intermediate-volume hospitals approached that of the high-volume quintile hospitals.⁵

Continue to: Minimum volume standards...

While efforts to regionalize surgical care have gradually evolved, calls have been growing to formalize policies that limit the performance of some procedures to surgeons and centers that meet a minimum volume threshold or standard.²¹ One such effort, based on consensus from 3 academic hospital systems, was a campaign for hospitals to “Take the Volume Pledge.”²¹ The campaign’s goal is to encourage health care systems to restrict the performance of 10 procedures to surgeons and hospitals within their systems that meet a minimum volume standard for the given operations.²¹ In essence, procedures would be restricted for low-volume providers and centers and triaged to higher-volume surgeons and hospitals within a given health care system.²¹

Proponents of the Volume Pledge argue that it is a relatively straightforward way to align patients and providers to optimize outcomes. The Volume Pledge focuses on larger hospital systems and encourages referral within the given system, thus mitigating competitive and financial concerns about referring patients to outside providers. Those who have argued against the Volume Pledge point out that the volume cut points chosen are somewhat arbitrary, that these policies have the potential to negatively impact rural hospitals and those serving smaller communities, and that quality is a more appropriate metric than volume.²² The Volume Pledge does not include any gynecologic procedures, and to date it has met with only limited success.²³

Perhaps more directly applicable to gynecologic surgeons are ongoing national trends to base hospital credentialing on surgical volume. In essence, individual surgeons must demonstrate that they have performed a minimum number of procedures to obtain or retain privileges.^24,25 While there is strong evidence of the association between volume and outcomes for some complex surgical procedures, linking volume to credentialing has a number of potential pitfalls. Studies of surgical outcomes based on volume represent average performance, and many low-volume providers have better-than-expected outcomes. Volume measures typically represent recent performance; it is difficult to measure the overall experience of individual surgeons. Similarly, surgical outcomes depend on both the surgeon and the system in which the surgeon operates. It is difficult, if not impossible, to account for differences in the environment in which a surgeon works.²⁵

A study of gynecologic surgeons who performed hysterectomy in New York State demonstrates many of the complexities of volume-based credentialing.²⁶ In a cohort of more than55,000 patients who underwent abdominal hysterectomy, there was a strong association between low surgeon volume and a higher-than-expected rate of complications. If one were to consider limiting privileges to even the lowest-volume providers, there would be a significant impact on the surgical workforce. In this cohort, limiting credentialing to the lowest-volume providers, those who performed only 1 abdominal hysterectomy in the prior year would restrict the privileges of 17.5% of the surgeons in the cohort. Further, in this low-volume cohort that performed only 1 abdominal hysterectomy in the prior year, 69% of the surgeons actually had outcomes that were better than predicted.²⁶ These data highlight not only the difficulty of applying averages to individual surgeons but also the profound impact that policy changes could have on the practice of gynecologic surgery.

Volume-outcomes paradigm discussions continue

The association between higher surgeon and hospital procedural volume for gynecologic surgeries and improved outcomes now has been convincingly demonstrated. With this knowledge, over the last decade the patterns of care for patients undergoing gynecologic surgery have clearly shifted, and these operations are now more commonly being performed by a smaller number of physicians and at fewer hospitals.

While efforts to improve quality are clearly important, many policy interventions, such as regionalization of care, have untoward consequences that must be considered. As we move forward, it will be essential to ensure that there is a robust debate among patients, providers, and policymakers on the merits of public health policies based on the volume-outcomes paradigm. ●

Over the last 3 decades, abundant evidence has demonstrated the association between surgical volume and outcomes. Patients operated on by high-volume surgeons and at high-volume hospitals have superior outcomes.^1,2 This relationship has provided a framework for a number of public health policies to try to align patients with appropriate providers and centers to optimize perioperative outcomes. In this article, we examine the volume-outcomes paradigm for gynecologic surgery and explore how this relationship is influencing patterns of care and policy.

Surgical volume in gynecology

The association between both hospital and surgeon volume and outcomes has been explored across a number of gynecologic procedures.³ A meta-analysis that included 741,000 patients found that low-volume surgeons had an increased rate of complications overall, a higher rate of intraoperative complications, and a higher rate of postoperative complications compared with high-volume surgeons. While there was no association between volume and mortality overall, when limited to gynecologic oncology studies, low surgeon volume was associated with increased perioperative mortality.³

While these studies demonstrated a statistically significant association between surgeon volume and perioperative outcomes, the magnitude of the effect is modest compared with other higher-risk procedures associated with greater perioperative morbidity. For example, in a large study that examined oncologic and cardiovascular surgery, perioperative mortality in patients who underwent pancreatic resection was reduced from 15% for low-volume surgeons to 5% for high-volume surgeons.¹ By contrast, for gynecologic surgery, complications occurred in 97 per 1,000 patients operated on by high-volume surgeons compared with between 114 and 137 per 1,000 for low-volume surgeons. Thus, to avoid 1 in-hospital complication, 30 surgeries performed by low-volume surgeons would need to be moved to high-volume surgeons. For intraoperative complications, 38 patients would need to be moved from low- to high-volume surgeons to prevent 1 such complication.³ In addition to morbidity and mortality, higher surgeon volume is associated with greater use of minimally invasive surgery, a lower likelihood of conversion to laparotomy, and lower costs.³

Continue to: Public health applications of gynecologic surgical volume...

Public health applications of gynecologic surgical volume

The large body of literature on volume and outcomes has led to a number of public health initiatives aimed at reducing perioperative morbidity and mortality. Broadly, these efforts focus on regionalization of care, targeted quality improvement, and the development of minimum volume standards. Each strategy holds promise but also the potential to lead to unwanted consequences.

Regionalization of care

Recognition of the volume-outcomes paradigm has led to efforts to regionalize care for complex procedures to high-volume surgeons and centers.¹⁰ A cohort study of surgical patterns of care for Medicare recipients who underwent cancer resections or abdominal aortic aneurysm repair from 1999 to 2008 demonstrated these shifting practice patterns. For example, in 1999–2000, pancreatectomy was performed in 1,308 hospitals, with a median case volume of 5 procedures per year. By 2007–2008, the number of hospitals in which pancreatectomy was performed declined to 978, and the median case volume rose to 16 procedures per year. Importantly, over this time period, risk-adjusted mortality for pancreatectomy declined by 19%, and increased hospital volume was responsible for more than two-thirds of the decline in mortality.¹⁰

There has similarly been a gradual concentration of some gynecologic procedures to higher-volume surgeons and centers.^11,12 Among patients undergoing hysterectomy for endometrial cancer in New York State, 845 surgeons with a mean case volume of 3 procedures per year treated patients in 2000. By 2014, the number of surgeons who performed these operations declined to 317 while mean annual case volume rose to 10 procedures per year. The number of hospitals in which women with endometrial cancer were treated declined from 182 to 98 over the same time period.¹¹ Similar trends were noted for patients undergoing ovarian cancer resection.¹² While patterns of gynecologic care for some surgical procedures have clearly changed, it has been more difficult to link these changes to improvements in outcomes.^11,12

Despite the intuitive appeal of regionalization of surgical care, such a strategy has a number of limitations and practical challenges. Not surprisingly, limiting the number of surgeons and hospitals that perform a given procedure necessitates that patients travel a greater distance to obtain necessary surgical care.^13,14 An analysis of endometrial cancer patients in New York State stratified patients based on their area of residence into 10 hospital referral regions (HRRs), which represent health care markets for tertiary medical care. From 2000 to 2014, the distance patients traveled to receive their surgical care increased in all of the HRRs studied. This was most pronounced in 1 of the HRRs in which the median travel distance rose by 47 miles over the 15-year period (FIGURE 1; FIGURE 2).¹⁴

Whether patients are willing to travel for care remains a matter of debate and depends on the disease, the surgical procedure, and the anticipated benefit associated with a longer travel distance.^15,16 In a discrete choice experiment, 100 participants were given a hypothetical scenario in which they had potentially resectable pancreatic cancer; they were queried on their willingness to travel for care based on varying differences in mortality between a local and regional hospital.¹⁵ When mortality at the local hospital was double that of the regional hospital (6% vs 3%), 45% of patients chose to remain at the local hospital. When the differential increased to a 4 times greater mortality at the local hospital (12% vs 3%), 23% of patients still chose to remain at the local hospital.¹⁵

Lastly, a number of studies have shown that regionalization of surgical care disproportionately affects Black and Hispanic patients and those with low socioeconomic status.^12,13,17 A simulation study on the effect of regionalizing care for pancreatectomy noted that using a hospital volume threshold of 20 procedures per year, a higher percentage of Black and Hispanic patients than White patients would be required to travel to a higher-volume center.¹³ Similarly, Medicaid recipients were more likely to be affected.¹³ Despite the inequities in who must travel for regionalized care, prior work has suggested that regionalization of cancer care to high-volume centers may reduce racial and socioeconomic disparities in survival for some cancers.¹⁸

Targeted quality improvement

Realizing the practical limitations of regionalization of care, an alternative strategy is to improve the quality of care at low-volume hospitals.^5,19 Quality of care and surgical volume often are correlated, and the delivery of high-quality care can mitigate some of the influence of surgical volume on outcomes.

These principles were demonstrated in a study of more than 100,000 patients with ovarian cancer that stratified treating hospitals into volume quintiles.⁵ As expected, survival (both 2- and 5-year) was highest in the highest-volume quintile hospitals (FIGURE 3).⁵ Similarly, quality of care, measured through adherence to various process measures, was also highest in the highest-volume quintile hospitals. Interestingly, in the second-fourth volume quintile hospitals, there was substantial variation in adherence to quality metrics. Among hospitals with higher quality care, an improved survival was noted compared with lower quality care hospitals within the same volume quintile. Survival at high-quality, intermediate-volume hospitals approached that of the high-volume quintile hospitals.⁵

Continue to: Minimum volume standards...

While efforts to regionalize surgical care have gradually evolved, calls have been growing to formalize policies that limit the performance of some procedures to surgeons and centers that meet a minimum volume threshold or standard.²¹ One such effort, based on consensus from 3 academic hospital systems, was a campaign for hospitals to “Take the Volume Pledge.”²¹ The campaign’s goal is to encourage health care systems to restrict the performance of 10 procedures to surgeons and hospitals within their systems that meet a minimum volume standard for the given operations.²¹ In essence, procedures would be restricted for low-volume providers and centers and triaged to higher-volume surgeons and hospitals within a given health care system.²¹

Proponents of the Volume Pledge argue that it is a relatively straightforward way to align patients and providers to optimize outcomes. The Volume Pledge focuses on larger hospital systems and encourages referral within the given system, thus mitigating competitive and financial concerns about referring patients to outside providers. Those who have argued against the Volume Pledge point out that the volume cut points chosen are somewhat arbitrary, that these policies have the potential to negatively impact rural hospitals and those serving smaller communities, and that quality is a more appropriate metric than volume.²² The Volume Pledge does not include any gynecologic procedures, and to date it has met with only limited success.²³

Perhaps more directly applicable to gynecologic surgeons are ongoing national trends to base hospital credentialing on surgical volume. In essence, individual surgeons must demonstrate that they have performed a minimum number of procedures to obtain or retain privileges.^24,25 While there is strong evidence of the association between volume and outcomes for some complex surgical procedures, linking volume to credentialing has a number of potential pitfalls. Studies of surgical outcomes based on volume represent average performance, and many low-volume providers have better-than-expected outcomes. Volume measures typically represent recent performance; it is difficult to measure the overall experience of individual surgeons. Similarly, surgical outcomes depend on both the surgeon and the system in which the surgeon operates. It is difficult, if not impossible, to account for differences in the environment in which a surgeon works.²⁵

A study of gynecologic surgeons who performed hysterectomy in New York State demonstrates many of the complexities of volume-based credentialing.²⁶ In a cohort of more than55,000 patients who underwent abdominal hysterectomy, there was a strong association between low surgeon volume and a higher-than-expected rate of complications. If one were to consider limiting privileges to even the lowest-volume providers, there would be a significant impact on the surgical workforce. In this cohort, limiting credentialing to the lowest-volume providers, those who performed only 1 abdominal hysterectomy in the prior year would restrict the privileges of 17.5% of the surgeons in the cohort. Further, in this low-volume cohort that performed only 1 abdominal hysterectomy in the prior year, 69% of the surgeons actually had outcomes that were better than predicted.²⁶ These data highlight not only the difficulty of applying averages to individual surgeons but also the profound impact that policy changes could have on the practice of gynecologic surgery.

Volume-outcomes paradigm discussions continue

The association between higher surgeon and hospital procedural volume for gynecologic surgeries and improved outcomes now has been convincingly demonstrated. With this knowledge, over the last decade the patterns of care for patients undergoing gynecologic surgery have clearly shifted, and these operations are now more commonly being performed by a smaller number of physicians and at fewer hospitals.

While efforts to improve quality are clearly important, many policy interventions, such as regionalization of care, have untoward consequences that must be considered. As we move forward, it will be essential to ensure that there is a robust debate among patients, providers, and policymakers on the merits of public health policies based on the volume-outcomes paradigm. ●

Over the last 3 decades, abundant evidence has demonstrated the association between surgical volume and outcomes. Patients operated on by high-volume surgeons and at high-volume hospitals have superior outcomes.^1,2 This relationship has provided a framework for a number of public health policies to try to align patients with appropriate providers and centers to optimize perioperative outcomes. In this article, we examine the volume-outcomes paradigm for gynecologic surgery and explore how this relationship is influencing patterns of care and policy.

Surgical volume in gynecology

The association between both hospital and surgeon volume and outcomes has been explored across a number of gynecologic procedures.³ A meta-analysis that included 741,000 patients found that low-volume surgeons had an increased rate of complications overall, a higher rate of intraoperative complications, and a higher rate of postoperative complications compared with high-volume surgeons. While there was no association between volume and mortality overall, when limited to gynecologic oncology studies, low surgeon volume was associated with increased perioperative mortality.³

While these studies demonstrated a statistically significant association between surgeon volume and perioperative outcomes, the magnitude of the effect is modest compared with other higher-risk procedures associated with greater perioperative morbidity. For example, in a large study that examined oncologic and cardiovascular surgery, perioperative mortality in patients who underwent pancreatic resection was reduced from 15% for low-volume surgeons to 5% for high-volume surgeons.¹ By contrast, for gynecologic surgery, complications occurred in 97 per 1,000 patients operated on by high-volume surgeons compared with between 114 and 137 per 1,000 for low-volume surgeons. Thus, to avoid 1 in-hospital complication, 30 surgeries performed by low-volume surgeons would need to be moved to high-volume surgeons. For intraoperative complications, 38 patients would need to be moved from low- to high-volume surgeons to prevent 1 such complication.³ In addition to morbidity and mortality, higher surgeon volume is associated with greater use of minimally invasive surgery, a lower likelihood of conversion to laparotomy, and lower costs.³

Continue to: Public health applications of gynecologic surgical volume...

Public health applications of gynecologic surgical volume

The large body of literature on volume and outcomes has led to a number of public health initiatives aimed at reducing perioperative morbidity and mortality. Broadly, these efforts focus on regionalization of care, targeted quality improvement, and the development of minimum volume standards. Each strategy holds promise but also the potential to lead to unwanted consequences.

Regionalization of care

Recognition of the volume-outcomes paradigm has led to efforts to regionalize care for complex procedures to high-volume surgeons and centers.¹⁰ A cohort study of surgical patterns of care for Medicare recipients who underwent cancer resections or abdominal aortic aneurysm repair from 1999 to 2008 demonstrated these shifting practice patterns. For example, in 1999–2000, pancreatectomy was performed in 1,308 hospitals, with a median case volume of 5 procedures per year. By 2007–2008, the number of hospitals in which pancreatectomy was performed declined to 978, and the median case volume rose to 16 procedures per year. Importantly, over this time period, risk-adjusted mortality for pancreatectomy declined by 19%, and increased hospital volume was responsible for more than two-thirds of the decline in mortality.¹⁰

There has similarly been a gradual concentration of some gynecologic procedures to higher-volume surgeons and centers.^11,12 Among patients undergoing hysterectomy for endometrial cancer in New York State, 845 surgeons with a mean case volume of 3 procedures per year treated patients in 2000. By 2014, the number of surgeons who performed these operations declined to 317 while mean annual case volume rose to 10 procedures per year. The number of hospitals in which women with endometrial cancer were treated declined from 182 to 98 over the same time period.¹¹ Similar trends were noted for patients undergoing ovarian cancer resection.¹² While patterns of gynecologic care for some surgical procedures have clearly changed, it has been more difficult to link these changes to improvements in outcomes.^11,12

Despite the intuitive appeal of regionalization of surgical care, such a strategy has a number of limitations and practical challenges. Not surprisingly, limiting the number of surgeons and hospitals that perform a given procedure necessitates that patients travel a greater distance to obtain necessary surgical care.^13,14 An analysis of endometrial cancer patients in New York State stratified patients based on their area of residence into 10 hospital referral regions (HRRs), which represent health care markets for tertiary medical care. From 2000 to 2014, the distance patients traveled to receive their surgical care increased in all of the HRRs studied. This was most pronounced in 1 of the HRRs in which the median travel distance rose by 47 miles over the 15-year period (FIGURE 1; FIGURE 2).¹⁴

Whether patients are willing to travel for care remains a matter of debate and depends on the disease, the surgical procedure, and the anticipated benefit associated with a longer travel distance.^15,16 In a discrete choice experiment, 100 participants were given a hypothetical scenario in which they had potentially resectable pancreatic cancer; they were queried on their willingness to travel for care based on varying differences in mortality between a local and regional hospital.¹⁵ When mortality at the local hospital was double that of the regional hospital (6% vs 3%), 45% of patients chose to remain at the local hospital. When the differential increased to a 4 times greater mortality at the local hospital (12% vs 3%), 23% of patients still chose to remain at the local hospital.¹⁵

Lastly, a number of studies have shown that regionalization of surgical care disproportionately affects Black and Hispanic patients and those with low socioeconomic status.^12,13,17 A simulation study on the effect of regionalizing care for pancreatectomy noted that using a hospital volume threshold of 20 procedures per year, a higher percentage of Black and Hispanic patients than White patients would be required to travel to a higher-volume center.¹³ Similarly, Medicaid recipients were more likely to be affected.¹³ Despite the inequities in who must travel for regionalized care, prior work has suggested that regionalization of cancer care to high-volume centers may reduce racial and socioeconomic disparities in survival for some cancers.¹⁸

Targeted quality improvement

Realizing the practical limitations of regionalization of care, an alternative strategy is to improve the quality of care at low-volume hospitals.^5,19 Quality of care and surgical volume often are correlated, and the delivery of high-quality care can mitigate some of the influence of surgical volume on outcomes.

These principles were demonstrated in a study of more than 100,000 patients with ovarian cancer that stratified treating hospitals into volume quintiles.⁵ As expected, survival (both 2- and 5-year) was highest in the highest-volume quintile hospitals (FIGURE 3).⁵ Similarly, quality of care, measured through adherence to various process measures, was also highest in the highest-volume quintile hospitals. Interestingly, in the second-fourth volume quintile hospitals, there was substantial variation in adherence to quality metrics. Among hospitals with higher quality care, an improved survival was noted compared with lower quality care hospitals within the same volume quintile. Survival at high-quality, intermediate-volume hospitals approached that of the high-volume quintile hospitals.⁵

Continue to: Minimum volume standards...

While efforts to regionalize surgical care have gradually evolved, calls have been growing to formalize policies that limit the performance of some procedures to surgeons and centers that meet a minimum volume threshold or standard.²¹ One such effort, based on consensus from 3 academic hospital systems, was a campaign for hospitals to “Take the Volume Pledge.”²¹ The campaign’s goal is to encourage health care systems to restrict the performance of 10 procedures to surgeons and hospitals within their systems that meet a minimum volume standard for the given operations.²¹ In essence, procedures would be restricted for low-volume providers and centers and triaged to higher-volume surgeons and hospitals within a given health care system.²¹

Proponents of the Volume Pledge argue that it is a relatively straightforward way to align patients and providers to optimize outcomes. The Volume Pledge focuses on larger hospital systems and encourages referral within the given system, thus mitigating competitive and financial concerns about referring patients to outside providers. Those who have argued against the Volume Pledge point out that the volume cut points chosen are somewhat arbitrary, that these policies have the potential to negatively impact rural hospitals and those serving smaller communities, and that quality is a more appropriate metric than volume.²² The Volume Pledge does not include any gynecologic procedures, and to date it has met with only limited success.²³

Perhaps more directly applicable to gynecologic surgeons are ongoing national trends to base hospital credentialing on surgical volume. In essence, individual surgeons must demonstrate that they have performed a minimum number of procedures to obtain or retain privileges.^24,25 While there is strong evidence of the association between volume and outcomes for some complex surgical procedures, linking volume to credentialing has a number of potential pitfalls. Studies of surgical outcomes based on volume represent average performance, and many low-volume providers have better-than-expected outcomes. Volume measures typically represent recent performance; it is difficult to measure the overall experience of individual surgeons. Similarly, surgical outcomes depend on both the surgeon and the system in which the surgeon operates. It is difficult, if not impossible, to account for differences in the environment in which a surgeon works.²⁵

A study of gynecologic surgeons who performed hysterectomy in New York State demonstrates many of the complexities of volume-based credentialing.²⁶ In a cohort of more than55,000 patients who underwent abdominal hysterectomy, there was a strong association between low surgeon volume and a higher-than-expected rate of complications. If one were to consider limiting privileges to even the lowest-volume providers, there would be a significant impact on the surgical workforce. In this cohort, limiting credentialing to the lowest-volume providers, those who performed only 1 abdominal hysterectomy in the prior year would restrict the privileges of 17.5% of the surgeons in the cohort. Further, in this low-volume cohort that performed only 1 abdominal hysterectomy in the prior year, 69% of the surgeons actually had outcomes that were better than predicted.²⁶ These data highlight not only the difficulty of applying averages to individual surgeons but also the profound impact that policy changes could have on the practice of gynecologic surgery.

Volume-outcomes paradigm discussions continue

The association between higher surgeon and hospital procedural volume for gynecologic surgeries and improved outcomes now has been convincingly demonstrated. With this knowledge, over the last decade the patterns of care for patients undergoing gynecologic surgery have clearly shifted, and these operations are now more commonly being performed by a smaller number of physicians and at fewer hospitals.

While efforts to improve quality are clearly important, many policy interventions, such as regionalization of care, have untoward consequences that must be considered. As we move forward, it will be essential to ensure that there is a robust debate among patients, providers, and policymakers on the merits of public health policies based on the volume-outcomes paradigm. ●

Work-related musculoskeletal disorders (WMSDs) are “musculoskeletal disorders (injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs) in which the work environment and performance of work contribute significantly to the condition; and/or the condition is made worse or persists longer due to work conditions.”¹ The health care industry has one of the highest rates of WMSDs, even when compared with traditional labor-intensive occupations, such as coal mining. In 2017, the health care industry reported more than a half million incidents of work-related injury and illness.^2,3 In particular, surgeons are at increased risk for WMSDs, since they repetitively perform the classic tenets of poor ergonomics, including operating in static, extreme, and awkward positions and for prolonged periods of time.³

Gynecologic surgeons face unique ergonomic challenges. Operating in the pelvis requires an oblique approach that adds complexity and inhibits appropriate ergonomic positioning.⁴ All modalities of surgery incur their own challenges and risks to the surgeon, including minimally invasive gynecologic surgery (MIGS), which has become the standard of care for most conditions. Although MIGS has several benefits for the patient, a survey of gynecologic oncologists found that 88% of respondents reported discomfort related to MIGS.⁵ Several factors contribute to the development of WMSDs in surgery, including lack of ergonomic awareness, suboptimal ergonomic education and training,^5,6 and ergonomically poor operating room (OR) equipment and instrument design.⁷ Furthermore, surgical culture does not generally prioritize ergonomics in the OR or requests for ergonomic accommodations.^7,8

Within 5 years, a physician workforce shortage is projected for the United States.⁹ WMSDs contribute to workforce issues as they are associated with decreased productivity; time off needed for pain and treatment, including short-term disability; and possibly early retirement (as those who are older and have more work experience may be more likely to seek medical attention).¹⁰ In a 2013 study of vaginal surgeons, 14% missed work; 21% modified their work hours, work type, or amount of surgery; and 29% modified their surgical technique because of injury.¹⁰ Work-related pain also can negatively affect mental health, sleep, relationships, and quality of life.⁶

Recently, awareness has increased regarding WMSDs and their consequences, which has led to significant strides in the study of ergonomics among surgeons, a growing body of research on the topic, and guidance for optimizing ergonomics in the OR.

Risk factors for ergonomic strain

Several factors contribute to ergonomic strain and, subsequently, the development of WMSDs. Recognizing these factors can direct strategies for injury prevention.

Patient factors

The prevalence of obesity in the United States increased from 30.5% in 1999–2000 to 41.9% between 2017 and 2020.¹¹ As the average patient’s body mass index (BMI) has increased, there is concern for a parallel increase in the ergonomic strain on laparoscopic surgeons.

A study of simulated laparoscopic tasks at varying model BMI levels demonstrated increased surgeon postural stress and workload at higher model BMIs (50 kg/m²) when compared with lower model BMIs (20 and 30 kg/m²).¹¹ This result was supported in another study, which demonstrated both increased muscle activity and increased time needed to complete a surgical task with laparoscopic surgery; interestingly, when the same study measured these parameters for robotic surgery, this association was not seen.¹² This suggests that a robotic rather than a laparoscopic approach may avoid some of the ergonomic strain associated with increased patient BMI.

Continue to: Surgeon factors...

Surgeon factors

Various surgeon characteristics have been shown to influence ergonomics in the OR. Surgeons with smaller hand sizes, for example, reported greater physical discomfort and demonstrated greater ergonomic workload when operating laparoscopically.^13-15 In particular, those with a glove size of 6.5 or smaller have more difficulty using laparoscopic instruments, and those with a glove size smaller than 7 demonstrate a larger decline in grip strength when using laparoscopic instruments repeatedly.^14,16

Surgeon height also can affect the amount of time spent in high-risk, nonergonomic positions. In a study that evaluated video recordings of surgeon posture during gynecologic laparoscopy, shorter surgeons were noted to use greater degrees of neck rotation to look at the monitor.¹⁷ Furthermore, surgeons with shorter arm lengths experienced more “extreme positions” of the nondominant shoulder and elbow.¹⁷ This trend also was seen in open and robotic surgery, where surgeons with a height of 66 cm or less reported increased pain scores after operating.¹⁸

Surgical instruments and OR setup

Surgical instrument characteristics can contribute to ergonomic strain, especially when the instruments have been designed with a one-size-fits-all mentality.^8,19 In an examination of the anthropometric measurements of surgeon hand sizes and their correlation with difficulty when using a “standard” laparoscopic instrument, surgeons with smaller finger and hand spans had trouble using these instruments.¹⁹ Another study compared surgeon grip strength and ergonomic workloads after using 3 laparoscopic advanced bipolar instruments.¹⁶ Gender and hand size aside, the authors found that use of several of the laparoscopic devices led to greater decline in grip strength.¹⁶

The setup of the OR also can have a profound effect on the surgeon’s ergonomics. Monitor placement, for example, is crucial to ergonomic success. One study found that positioning the monitor directly in front of the surgeon at eye level was associated with the lowest neck muscle activity during a simulated task.²⁰

Route of surgery

Each surgical approach has intrinsic ergonomic risks. With laparoscopy, surgeons often remain in straight head and back positions without much trunk motion, especially when compared with open surgery.²¹ In one study, laparoscopic surgeons spent more than 60% of a case in a static position and more than 80% of a case in a high-risk, “demanding” neck position.²²

Robotic surgery, in contrast to laparoscopy, often has been cited as being more “ergonomic.” While robotic surgery has less of an effect on the neck, shoulders, arms, and legs than laparoscopy²³ and often is associated with less physical discomfort than either open or laparoscopic surgery,^23,24 robotic surgery still maintains its own innate ergonomic risks. Of robotic surgeons surveyed, 56.1% reported neck stiffness, finger fatigue, and eye symptoms in one study.²⁵ In another survey study, more robotic surgeons (72%) reported physical symptoms than laparoscopic (57%) and open (49%) surgeons.²⁶Vaginal surgery also puts surgeons at ergonomic risk. A majority of surgeons (87.2%) who completed more than 50% of their cases vaginally reported a history of WMSDs.¹⁰ Vaginal surgery places surgeons in awkward positions of the neck, shoulder, and trunk frequently and for longer durations.²⁷

Continue to: Strategies for preventing WMSDs...

Strategies for preventing WMSDs

As factors that contribute to the development of WMSDs are identified, preventive strategies can be targeted to these individual factors. Research has focused on appropriate setup of the OR, surgeon posture, intraoperative microbreaks, and stretching both in and outside of the OR.

1. OR setup and positioning of the surgeon by MIGS route

The route of MIGS affects OR setup and surgeon posture. Ergonomic recommendations for laparoscopy, robotic surgery, and vaginal surgery are all unique to the risks posed by each particular approach.

Laparoscopic surgery. Laparoscopic monitors should face the surgeon directly, with the screen just below eye level to maintain the surgeon’s neck in a neutral position.²⁸ The table height should be set for the tallest surgeon, and shorter surgeons should stand on steps as needed.²⁸ The table height also should allow for the surgeon’s hands to be at elbow height, with the elbows bent at 90 degrees with the wrists straight.²⁹ Foot pedals should be placed at the surgeons’ foot level and should be reached easily.²⁸ Additionally, the patient’s arms should be tucked at their sides to allow surgeons a larger operative space.²⁹ When using laparoscopic instruments, locking and ratcheting features should be used whenever possible to reduce prolonged grip or squeeze forces.²⁸ The laparoscopic camera should be held in the palm with the wrist in a neutral position.²⁹

Robotic surgery. Positioning and setup of the robotic console is a main focus of ergonomic recommendations. The surgeon’s chair should be brought as close to the console as possible, and the knees positioned in a 90-degree angle.³⁰ The foot pedals should be brought toward the surgeon to maintain this angle of the knees.³⁰ The console should be rotated toward the surgeon and then the height adjusted so that the surgeon can look through the eyepiece while sitting upright and can maintain the neck in a neutral position.^28,30 The surgeon’s forehead should rest comfortably on the headrest.²⁹ The forearms should rest on the armrest while the arms are maintained in a neutral position and the shoulders remain relaxed while the surgeon holds the robotic controls.³⁰ It is important to utilize the armrest often to relieve stress on the arm while operating.²⁸ Frequent use of the clutch function can keep the robotic controls in the center of the workspace.²⁸

Vaginal surgery. Both seated and standing positions are associated with high-risk positioning of the trunk and bilateral shoulders, respectively, in vaginal surgery.³¹ However, surgeons who stand while operating vaginally reported more discomfort in the bilateral wrists, thighs, and lower legs than those who operated while seated.³¹ This suggests a potential ergonomic advantage to the seated position for vaginal surgery. Chair height should be adjusted so the surgeon can look straight ahead with the neck in a neutral position.³² Surgeons should consider using a headlamp, as this may prevent repetitive awkward movements to adjust overhead lights.³² For standing surgery, the table height should be adjusted for the tallest surgeon, and shorter surgeons or assistants should use steps as needed.³

Surgical assistants should switch sides during the course of the case to avoid excessive unilateral upper-extremity strain.³² The addition of a table-mounted vaginal retractor system may be useful in relieving physical strain for surgical assistants, but data currently are lacking to demonstrate this ergonomic benefit.³³ Further studies are needed, especially since many surgeons take on the role of surgical assist in the teaching environment and subsequently report more WMSDs than their colleagues who do not work in teaching environments.^10,34

2. Pain relief from individual ergonomic positioning devices

Apart from adjusting how the OR equipment is arranged or how the surgeons adjust their positioning, several devices that assist with surgeon positioning—including gel mats or insoles, exoskeletons, and “augmented reality” glasses—are being studied.

The use of gel mats or insoles in the OR has mixed evidence in the literature.^35-37

Exoskeletons, external devices that support a surgeon’s posture and positioning, have been studied thus far in simulated nonsterile surgical environments. Preliminarily, it appears that use of an exoskeleton can decrease muscle activity and time spent in static positions, with a reported decrease in post-task user discomfort.^38,39 More data are needed to determine if exoskeletons can be used in the sterile setting and for longer durations as may occur in actual OR cases.

Augmented reality glasses project the laparoscopic monitor image to the glasses, which frees the surgeon to place the “monitor” in a more neutral, ergonomic position. In one study, use of augmented reality glasses was associated with decreased muscle activity and a reduction in Rapid Entire Body Assessment (REBA) scores when compared with use of the conventional laparoscopic monitor.⁴⁰More data are needed on these emerging technologies to determine whether adverse effects occur with prolonged use.

Continue to: 3. Implementing intraoperative microbreaks and stretching...

The American College of Surgeons (ACS) recommends that surgeons avoid prolonged static postures during procedures.²⁸ One strategy for preventing sustained positioning is to incorporate breaks with associated stretching routinely during surgery.²⁸

Microbreaks. In a landmark study by Park and colleagues in 2017, 120-second long targeted stretching microbreaks (TSMBs) were completed every 20 to 40 minutes during a surgery, and results demonstrated improved postoperative surgeon pain scores without an associated increase in the length of the case.⁴¹ These surgeons reported improved pain in the neck, bilateral shoulders, bilateral hands, and lower back. Eighty-eight percent of surgeons reported either improvement or “no change” in their mental focus, and 100% reported improvement or “no change” in their physical performance after TSMBs were implemented.⁴² Of surveyed surgeons, 87% wanted TSMBs incorporated routinely.^41,42

Stretches. Multiple resources, such as the ACS and the Mayo Clinic, for intraoperative stretches are available. The ACS recommends performing neck and shoulder stretches during intraoperative microbreaks, including a range-of-movement neck exercise, deep cervical flexor training, and standing scapular retraction.²⁸ The ACS also demonstrates lumbrical stretches for the fingers and passive wrist extension exercises to be used intraoperatively (or between cases) (FIGURE 1).²⁸ The Mayo Clinic Hallbeck Human Factors Engineering Laboratories has a publicly available “OR Stretch Instructional Video” in which the surgeon is guided through several different short stretches, including shoulder shrugging and side bends, that can be used during surgery.⁴³

Both the ACS and the Mayo Clinic provide examples of pertinent stretch exercises for use when not in the sterile environment, between cases or after cases are complete. The ACS recommends several neck and shoulder stretches for the trapezius, levator scapulae, and pectoralis and recommends the use of a foam roller to improve thoracic mobility (FIGURE 2).²⁸ As above, the Mayo Clinic Hallbeck Human Factors Engineering Laboratories has a publicly available “OR-Stretch Between Surgery Stretches Video” in which the surgeon is guided through several short stretches that are done in a seated position, including stretches for the hamstring, lower back, and arms (FIGURE 3).⁴³

Many of the above-mentioned stretches were designed for use in the context of open, laparoscopic, or robotic surgery. For the vaginal surgeon, the intraoperative ergonomic stressors differ from those of other routes of surgery, and thus stretches tailored to the positioning during vaginal surgery are necessary. In a video recently published by the Society of Gynecologic Surgeons, several stretches are reviewed that target high-risk positions often held by the surgeon or assistant when operating vaginally.⁴⁴ These stretches include cervical retraction, thoracic extension, external arm rotation, cervical side bending, and lumbar extension (FIGURE 4).⁴⁴ The recommendation is to complete these exercises 2 times per day, with 8 to 10 repetitions per set.⁴⁴

Prioritizing ergonomic awareness and training

As caregivers, it is not uncommon for us to prioritize the needs of others before those of ourselves. However, WMSDs are prevalent, and their downstream effects may cause catastrophic professional and personal losses. Cumulatively, the global impact of WMSDs is a significant issue for the health care workforce and its longevity.

To prevent WMSDs, it is imperative that surgeons are aware of the factors that contribute to injury development and the appropriate, accessible modifications for these factors. While each surgical modality confers its own ergonomic challenges, these risks can be mitigated through increased awareness of OR setup, surgeon positioning, and incorporation of microbreaks and stretching exercises during and after surgical procedures.

Formal training in surgical ergonomics is lacking across specialties, including gynecology.⁴⁵ Multiple educational interventions have been proposed and studied to help fill this training gap.^30,46-49When used, these interventions have been associated with increased knowledge of surgical ergonomic principles or reduction in surgeon pain scores, including trainees.⁵⁰ As we become more cognizant of WMSDs, standardized resident curricula should be developed in an effort to reduce the prevalence of these potentially career-ending injuries.

In addition to education, cultivating a culture in which ergonomics is prioritized is essential. Although most surgeons report work-related pain, very few report their injuries to occupational health. For example, while 29% of gynecologic oncologists reported seeking treatment for a WMSD, only 1% had reported their injury to their employer.⁵ In a study of ACS members, only 19% of injuries were reported, 30% of surgeons stated that they did not know how to report an injury, and 21% felt that the resources for surgeons during and after an injury were inadequate.⁶

As we prioritize the health and safety of our patients, we also need to promote ergonomic awareness in the OR, respect the need for accommodations, encourage injury reporting, support surgeons who need to take time away for medical treatment, and partner with industry to develop new instruments and technology with effective ergonomic features. ●

Work-related musculoskeletal disorders (WMSDs) are “musculoskeletal disorders (injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs) in which the work environment and performance of work contribute significantly to the condition; and/or the condition is made worse or persists longer due to work conditions.”¹ The health care industry has one of the highest rates of WMSDs, even when compared with traditional labor-intensive occupations, such as coal mining. In 2017, the health care industry reported more than a half million incidents of work-related injury and illness.^2,3 In particular, surgeons are at increased risk for WMSDs, since they repetitively perform the classic tenets of poor ergonomics, including operating in static, extreme, and awkward positions and for prolonged periods of time.³

Gynecologic surgeons face unique ergonomic challenges. Operating in the pelvis requires an oblique approach that adds complexity and inhibits appropriate ergonomic positioning.⁴ All modalities of surgery incur their own challenges and risks to the surgeon, including minimally invasive gynecologic surgery (MIGS), which has become the standard of care for most conditions. Although MIGS has several benefits for the patient, a survey of gynecologic oncologists found that 88% of respondents reported discomfort related to MIGS.⁵ Several factors contribute to the development of WMSDs in surgery, including lack of ergonomic awareness, suboptimal ergonomic education and training,^5,6 and ergonomically poor operating room (OR) equipment and instrument design.⁷ Furthermore, surgical culture does not generally prioritize ergonomics in the OR or requests for ergonomic accommodations.^7,8

Within 5 years, a physician workforce shortage is projected for the United States.⁹ WMSDs contribute to workforce issues as they are associated with decreased productivity; time off needed for pain and treatment, including short-term disability; and possibly early retirement (as those who are older and have more work experience may be more likely to seek medical attention).¹⁰ In a 2013 study of vaginal surgeons, 14% missed work; 21% modified their work hours, work type, or amount of surgery; and 29% modified their surgical technique because of injury.¹⁰ Work-related pain also can negatively affect mental health, sleep, relationships, and quality of life.⁶

Recently, awareness has increased regarding WMSDs and their consequences, which has led to significant strides in the study of ergonomics among surgeons, a growing body of research on the topic, and guidance for optimizing ergonomics in the OR.

Risk factors for ergonomic strain

Several factors contribute to ergonomic strain and, subsequently, the development of WMSDs. Recognizing these factors can direct strategies for injury prevention.

Patient factors

The prevalence of obesity in the United States increased from 30.5% in 1999–2000 to 41.9% between 2017 and 2020.¹¹ As the average patient’s body mass index (BMI) has increased, there is concern for a parallel increase in the ergonomic strain on laparoscopic surgeons.

A study of simulated laparoscopic tasks at varying model BMI levels demonstrated increased surgeon postural stress and workload at higher model BMIs (50 kg/m²) when compared with lower model BMIs (20 and 30 kg/m²).¹¹ This result was supported in another study, which demonstrated both increased muscle activity and increased time needed to complete a surgical task with laparoscopic surgery; interestingly, when the same study measured these parameters for robotic surgery, this association was not seen.¹² This suggests that a robotic rather than a laparoscopic approach may avoid some of the ergonomic strain associated with increased patient BMI.

Continue to: Surgeon factors...

Surgeon factors

Various surgeon characteristics have been shown to influence ergonomics in the OR. Surgeons with smaller hand sizes, for example, reported greater physical discomfort and demonstrated greater ergonomic workload when operating laparoscopically.^13-15 In particular, those with a glove size of 6.5 or smaller have more difficulty using laparoscopic instruments, and those with a glove size smaller than 7 demonstrate a larger decline in grip strength when using laparoscopic instruments repeatedly.^14,16

Surgeon height also can affect the amount of time spent in high-risk, nonergonomic positions. In a study that evaluated video recordings of surgeon posture during gynecologic laparoscopy, shorter surgeons were noted to use greater degrees of neck rotation to look at the monitor.¹⁷ Furthermore, surgeons with shorter arm lengths experienced more “extreme positions” of the nondominant shoulder and elbow.¹⁷ This trend also was seen in open and robotic surgery, where surgeons with a height of 66 cm or less reported increased pain scores after operating.¹⁸

Surgical instruments and OR setup

Surgical instrument characteristics can contribute to ergonomic strain, especially when the instruments have been designed with a one-size-fits-all mentality.^8,19 In an examination of the anthropometric measurements of surgeon hand sizes and their correlation with difficulty when using a “standard” laparoscopic instrument, surgeons with smaller finger and hand spans had trouble using these instruments.¹⁹ Another study compared surgeon grip strength and ergonomic workloads after using 3 laparoscopic advanced bipolar instruments.¹⁶ Gender and hand size aside, the authors found that use of several of the laparoscopic devices led to greater decline in grip strength.¹⁶

The setup of the OR also can have a profound effect on the surgeon’s ergonomics. Monitor placement, for example, is crucial to ergonomic success. One study found that positioning the monitor directly in front of the surgeon at eye level was associated with the lowest neck muscle activity during a simulated task.²⁰

Route of surgery

Each surgical approach has intrinsic ergonomic risks. With laparoscopy, surgeons often remain in straight head and back positions without much trunk motion, especially when compared with open surgery.²¹ In one study, laparoscopic surgeons spent more than 60% of a case in a static position and more than 80% of a case in a high-risk, “demanding” neck position.²²

Robotic surgery, in contrast to laparoscopy, often has been cited as being more “ergonomic.” While robotic surgery has less of an effect on the neck, shoulders, arms, and legs than laparoscopy²³ and often is associated with less physical discomfort than either open or laparoscopic surgery,^23,24 robotic surgery still maintains its own innate ergonomic risks. Of robotic surgeons surveyed, 56.1% reported neck stiffness, finger fatigue, and eye symptoms in one study.²⁵ In another survey study, more robotic surgeons (72%) reported physical symptoms than laparoscopic (57%) and open (49%) surgeons.²⁶Vaginal surgery also puts surgeons at ergonomic risk. A majority of surgeons (87.2%) who completed more than 50% of their cases vaginally reported a history of WMSDs.¹⁰ Vaginal surgery places surgeons in awkward positions of the neck, shoulder, and trunk frequently and for longer durations.²⁷

Continue to: Strategies for preventing WMSDs...

Strategies for preventing WMSDs

As factors that contribute to the development of WMSDs are identified, preventive strategies can be targeted to these individual factors. Research has focused on appropriate setup of the OR, surgeon posture, intraoperative microbreaks, and stretching both in and outside of the OR.

1. OR setup and positioning of the surgeon by MIGS route

The route of MIGS affects OR setup and surgeon posture. Ergonomic recommendations for laparoscopy, robotic surgery, and vaginal surgery are all unique to the risks posed by each particular approach.

Laparoscopic surgery. Laparoscopic monitors should face the surgeon directly, with the screen just below eye level to maintain the surgeon’s neck in a neutral position.²⁸ The table height should be set for the tallest surgeon, and shorter surgeons should stand on steps as needed.²⁸ The table height also should allow for the surgeon’s hands to be at elbow height, with the elbows bent at 90 degrees with the wrists straight.²⁹ Foot pedals should be placed at the surgeons’ foot level and should be reached easily.²⁸ Additionally, the patient’s arms should be tucked at their sides to allow surgeons a larger operative space.²⁹ When using laparoscopic instruments, locking and ratcheting features should be used whenever possible to reduce prolonged grip or squeeze forces.²⁸ The laparoscopic camera should be held in the palm with the wrist in a neutral position.²⁹

Robotic surgery. Positioning and setup of the robotic console is a main focus of ergonomic recommendations. The surgeon’s chair should be brought as close to the console as possible, and the knees positioned in a 90-degree angle.³⁰ The foot pedals should be brought toward the surgeon to maintain this angle of the knees.³⁰ The console should be rotated toward the surgeon and then the height adjusted so that the surgeon can look through the eyepiece while sitting upright and can maintain the neck in a neutral position.^28,30 The surgeon’s forehead should rest comfortably on the headrest.²⁹ The forearms should rest on the armrest while the arms are maintained in a neutral position and the shoulders remain relaxed while the surgeon holds the robotic controls.³⁰ It is important to utilize the armrest often to relieve stress on the arm while operating.²⁸ Frequent use of the clutch function can keep the robotic controls in the center of the workspace.²⁸

Vaginal surgery. Both seated and standing positions are associated with high-risk positioning of the trunk and bilateral shoulders, respectively, in vaginal surgery.³¹ However, surgeons who stand while operating vaginally reported more discomfort in the bilateral wrists, thighs, and lower legs than those who operated while seated.³¹ This suggests a potential ergonomic advantage to the seated position for vaginal surgery. Chair height should be adjusted so the surgeon can look straight ahead with the neck in a neutral position.³² Surgeons should consider using a headlamp, as this may prevent repetitive awkward movements to adjust overhead lights.³² For standing surgery, the table height should be adjusted for the tallest surgeon, and shorter surgeons or assistants should use steps as needed.³

Surgical assistants should switch sides during the course of the case to avoid excessive unilateral upper-extremity strain.³² The addition of a table-mounted vaginal retractor system may be useful in relieving physical strain for surgical assistants, but data currently are lacking to demonstrate this ergonomic benefit.³³ Further studies are needed, especially since many surgeons take on the role of surgical assist in the teaching environment and subsequently report more WMSDs than their colleagues who do not work in teaching environments.^10,34

2. Pain relief from individual ergonomic positioning devices

Apart from adjusting how the OR equipment is arranged or how the surgeons adjust their positioning, several devices that assist with surgeon positioning—including gel mats or insoles, exoskeletons, and “augmented reality” glasses—are being studied.

The use of gel mats or insoles in the OR has mixed evidence in the literature.^35-37

Exoskeletons, external devices that support a surgeon’s posture and positioning, have been studied thus far in simulated nonsterile surgical environments. Preliminarily, it appears that use of an exoskeleton can decrease muscle activity and time spent in static positions, with a reported decrease in post-task user discomfort.^38,39 More data are needed to determine if exoskeletons can be used in the sterile setting and for longer durations as may occur in actual OR cases.

Augmented reality glasses project the laparoscopic monitor image to the glasses, which frees the surgeon to place the “monitor” in a more neutral, ergonomic position. In one study, use of augmented reality glasses was associated with decreased muscle activity and a reduction in Rapid Entire Body Assessment (REBA) scores when compared with use of the conventional laparoscopic monitor.⁴⁰More data are needed on these emerging technologies to determine whether adverse effects occur with prolonged use.

Continue to: 3. Implementing intraoperative microbreaks and stretching...

The American College of Surgeons (ACS) recommends that surgeons avoid prolonged static postures during procedures.²⁸ One strategy for preventing sustained positioning is to incorporate breaks with associated stretching routinely during surgery.²⁸

Microbreaks. In a landmark study by Park and colleagues in 2017, 120-second long targeted stretching microbreaks (TSMBs) were completed every 20 to 40 minutes during a surgery, and results demonstrated improved postoperative surgeon pain scores without an associated increase in the length of the case.⁴¹ These surgeons reported improved pain in the neck, bilateral shoulders, bilateral hands, and lower back. Eighty-eight percent of surgeons reported either improvement or “no change” in their mental focus, and 100% reported improvement or “no change” in their physical performance after TSMBs were implemented.⁴² Of surveyed surgeons, 87% wanted TSMBs incorporated routinely.^41,42

Stretches. Multiple resources, such as the ACS and the Mayo Clinic, for intraoperative stretches are available. The ACS recommends performing neck and shoulder stretches during intraoperative microbreaks, including a range-of-movement neck exercise, deep cervical flexor training, and standing scapular retraction.²⁸ The ACS also demonstrates lumbrical stretches for the fingers and passive wrist extension exercises to be used intraoperatively (or between cases) (FIGURE 1).²⁸ The Mayo Clinic Hallbeck Human Factors Engineering Laboratories has a publicly available “OR Stretch Instructional Video” in which the surgeon is guided through several different short stretches, including shoulder shrugging and side bends, that can be used during surgery.⁴³

Both the ACS and the Mayo Clinic provide examples of pertinent stretch exercises for use when not in the sterile environment, between cases or after cases are complete. The ACS recommends several neck and shoulder stretches for the trapezius, levator scapulae, and pectoralis and recommends the use of a foam roller to improve thoracic mobility (FIGURE 2).²⁸ As above, the Mayo Clinic Hallbeck Human Factors Engineering Laboratories has a publicly available “OR-Stretch Between Surgery Stretches Video” in which the surgeon is guided through several short stretches that are done in a seated position, including stretches for the hamstring, lower back, and arms (FIGURE 3).⁴³

Many of the above-mentioned stretches were designed for use in the context of open, laparoscopic, or robotic surgery. For the vaginal surgeon, the intraoperative ergonomic stressors differ from those of other routes of surgery, and thus stretches tailored to the positioning during vaginal surgery are necessary. In a video recently published by the Society of Gynecologic Surgeons, several stretches are reviewed that target high-risk positions often held by the surgeon or assistant when operating vaginally.⁴⁴ These stretches include cervical retraction, thoracic extension, external arm rotation, cervical side bending, and lumbar extension (FIGURE 4).⁴⁴ The recommendation is to complete these exercises 2 times per day, with 8 to 10 repetitions per set.⁴⁴

Prioritizing ergonomic awareness and training

As caregivers, it is not uncommon for us to prioritize the needs of others before those of ourselves. However, WMSDs are prevalent, and their downstream effects may cause catastrophic professional and personal losses. Cumulatively, the global impact of WMSDs is a significant issue for the health care workforce and its longevity.

To prevent WMSDs, it is imperative that surgeons are aware of the factors that contribute to injury development and the appropriate, accessible modifications for these factors. While each surgical modality confers its own ergonomic challenges, these risks can be mitigated through increased awareness of OR setup, surgeon positioning, and incorporation of microbreaks and stretching exercises during and after surgical procedures.

Formal training in surgical ergonomics is lacking across specialties, including gynecology.⁴⁵ Multiple educational interventions have been proposed and studied to help fill this training gap.^30,46-49When used, these interventions have been associated with increased knowledge of surgical ergonomic principles or reduction in surgeon pain scores, including trainees.⁵⁰ As we become more cognizant of WMSDs, standardized resident curricula should be developed in an effort to reduce the prevalence of these potentially career-ending injuries.

In addition to education, cultivating a culture in which ergonomics is prioritized is essential. Although most surgeons report work-related pain, very few report their injuries to occupational health. For example, while 29% of gynecologic oncologists reported seeking treatment for a WMSD, only 1% had reported their injury to their employer.⁵ In a study of ACS members, only 19% of injuries were reported, 30% of surgeons stated that they did not know how to report an injury, and 21% felt that the resources for surgeons during and after an injury were inadequate.⁶

As we prioritize the health and safety of our patients, we also need to promote ergonomic awareness in the OR, respect the need for accommodations, encourage injury reporting, support surgeons who need to take time away for medical treatment, and partner with industry to develop new instruments and technology with effective ergonomic features. ●

Work-related musculoskeletal disorders (WMSDs) are “musculoskeletal disorders (injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs) in which the work environment and performance of work contribute significantly to the condition; and/or the condition is made worse or persists longer due to work conditions.”¹ The health care industry has one of the highest rates of WMSDs, even when compared with traditional labor-intensive occupations, such as coal mining. In 2017, the health care industry reported more than a half million incidents of work-related injury and illness.^2,3 In particular, surgeons are at increased risk for WMSDs, since they repetitively perform the classic tenets of poor ergonomics, including operating in static, extreme, and awkward positions and for prolonged periods of time.³

Gynecologic surgeons face unique ergonomic challenges. Operating in the pelvis requires an oblique approach that adds complexity and inhibits appropriate ergonomic positioning.⁴ All modalities of surgery incur their own challenges and risks to the surgeon, including minimally invasive gynecologic surgery (MIGS), which has become the standard of care for most conditions. Although MIGS has several benefits for the patient, a survey of gynecologic oncologists found that 88% of respondents reported discomfort related to MIGS.⁵ Several factors contribute to the development of WMSDs in surgery, including lack of ergonomic awareness, suboptimal ergonomic education and training,^5,6 and ergonomically poor operating room (OR) equipment and instrument design.⁷ Furthermore, surgical culture does not generally prioritize ergonomics in the OR or requests for ergonomic accommodations.^7,8

Within 5 years, a physician workforce shortage is projected for the United States.⁹ WMSDs contribute to workforce issues as they are associated with decreased productivity; time off needed for pain and treatment, including short-term disability; and possibly early retirement (as those who are older and have more work experience may be more likely to seek medical attention).¹⁰ In a 2013 study of vaginal surgeons, 14% missed work; 21% modified their work hours, work type, or amount of surgery; and 29% modified their surgical technique because of injury.¹⁰ Work-related pain also can negatively affect mental health, sleep, relationships, and quality of life.⁶

Recently, awareness has increased regarding WMSDs and their consequences, which has led to significant strides in the study of ergonomics among surgeons, a growing body of research on the topic, and guidance for optimizing ergonomics in the OR.

Risk factors for ergonomic strain

Several factors contribute to ergonomic strain and, subsequently, the development of WMSDs. Recognizing these factors can direct strategies for injury prevention.

Patient factors

The prevalence of obesity in the United States increased from 30.5% in 1999–2000 to 41.9% between 2017 and 2020.¹¹ As the average patient’s body mass index (BMI) has increased, there is concern for a parallel increase in the ergonomic strain on laparoscopic surgeons.

A study of simulated laparoscopic tasks at varying model BMI levels demonstrated increased surgeon postural stress and workload at higher model BMIs (50 kg/m²) when compared with lower model BMIs (20 and 30 kg/m²).¹¹ This result was supported in another study, which demonstrated both increased muscle activity and increased time needed to complete a surgical task with laparoscopic surgery; interestingly, when the same study measured these parameters for robotic surgery, this association was not seen.¹² This suggests that a robotic rather than a laparoscopic approach may avoid some of the ergonomic strain associated with increased patient BMI.

Continue to: Surgeon factors...

Surgeon factors

Various surgeon characteristics have been shown to influence ergonomics in the OR. Surgeons with smaller hand sizes, for example, reported greater physical discomfort and demonstrated greater ergonomic workload when operating laparoscopically.^13-15 In particular, those with a glove size of 6.5 or smaller have more difficulty using laparoscopic instruments, and those with a glove size smaller than 7 demonstrate a larger decline in grip strength when using laparoscopic instruments repeatedly.^14,16

Surgeon height also can affect the amount of time spent in high-risk, nonergonomic positions. In a study that evaluated video recordings of surgeon posture during gynecologic laparoscopy, shorter surgeons were noted to use greater degrees of neck rotation to look at the monitor.¹⁷ Furthermore, surgeons with shorter arm lengths experienced more “extreme positions” of the nondominant shoulder and elbow.¹⁷ This trend also was seen in open and robotic surgery, where surgeons with a height of 66 cm or less reported increased pain scores after operating.¹⁸

Surgical instruments and OR setup

Surgical instrument characteristics can contribute to ergonomic strain, especially when the instruments have been designed with a one-size-fits-all mentality.^8,19 In an examination of the anthropometric measurements of surgeon hand sizes and their correlation with difficulty when using a “standard” laparoscopic instrument, surgeons with smaller finger and hand spans had trouble using these instruments.¹⁹ Another study compared surgeon grip strength and ergonomic workloads after using 3 laparoscopic advanced bipolar instruments.¹⁶ Gender and hand size aside, the authors found that use of several of the laparoscopic devices led to greater decline in grip strength.¹⁶

The setup of the OR also can have a profound effect on the surgeon’s ergonomics. Monitor placement, for example, is crucial to ergonomic success. One study found that positioning the monitor directly in front of the surgeon at eye level was associated with the lowest neck muscle activity during a simulated task.²⁰

Route of surgery

Each surgical approach has intrinsic ergonomic risks. With laparoscopy, surgeons often remain in straight head and back positions without much trunk motion, especially when compared with open surgery.²¹ In one study, laparoscopic surgeons spent more than 60% of a case in a static position and more than 80% of a case in a high-risk, “demanding” neck position.²²

Robotic surgery, in contrast to laparoscopy, often has been cited as being more “ergonomic.” While robotic surgery has less of an effect on the neck, shoulders, arms, and legs than laparoscopy²³ and often is associated with less physical discomfort than either open or laparoscopic surgery,^23,24 robotic surgery still maintains its own innate ergonomic risks. Of robotic surgeons surveyed, 56.1% reported neck stiffness, finger fatigue, and eye symptoms in one study.²⁵ In another survey study, more robotic surgeons (72%) reported physical symptoms than laparoscopic (57%) and open (49%) surgeons.²⁶Vaginal surgery also puts surgeons at ergonomic risk. A majority of surgeons (87.2%) who completed more than 50% of their cases vaginally reported a history of WMSDs.¹⁰ Vaginal surgery places surgeons in awkward positions of the neck, shoulder, and trunk frequently and for longer durations.²⁷

Continue to: Strategies for preventing WMSDs...

Strategies for preventing WMSDs

As factors that contribute to the development of WMSDs are identified, preventive strategies can be targeted to these individual factors. Research has focused on appropriate setup of the OR, surgeon posture, intraoperative microbreaks, and stretching both in and outside of the OR.

1. OR setup and positioning of the surgeon by MIGS route

The route of MIGS affects OR setup and surgeon posture. Ergonomic recommendations for laparoscopy, robotic surgery, and vaginal surgery are all unique to the risks posed by each particular approach.

Laparoscopic surgery. Laparoscopic monitors should face the surgeon directly, with the screen just below eye level to maintain the surgeon’s neck in a neutral position.²⁸ The table height should be set for the tallest surgeon, and shorter surgeons should stand on steps as needed.²⁸ The table height also should allow for the surgeon’s hands to be at elbow height, with the elbows bent at 90 degrees with the wrists straight.²⁹ Foot pedals should be placed at the surgeons’ foot level and should be reached easily.²⁸ Additionally, the patient’s arms should be tucked at their sides to allow surgeons a larger operative space.²⁹ When using laparoscopic instruments, locking and ratcheting features should be used whenever possible to reduce prolonged grip or squeeze forces.²⁸ The laparoscopic camera should be held in the palm with the wrist in a neutral position.²⁹

Robotic surgery. Positioning and setup of the robotic console is a main focus of ergonomic recommendations. The surgeon’s chair should be brought as close to the console as possible, and the knees positioned in a 90-degree angle.³⁰ The foot pedals should be brought toward the surgeon to maintain this angle of the knees.³⁰ The console should be rotated toward the surgeon and then the height adjusted so that the surgeon can look through the eyepiece while sitting upright and can maintain the neck in a neutral position.^28,30 The surgeon’s forehead should rest comfortably on the headrest.²⁹ The forearms should rest on the armrest while the arms are maintained in a neutral position and the shoulders remain relaxed while the surgeon holds the robotic controls.³⁰ It is important to utilize the armrest often to relieve stress on the arm while operating.²⁸ Frequent use of the clutch function can keep the robotic controls in the center of the workspace.²⁸

Vaginal surgery. Both seated and standing positions are associated with high-risk positioning of the trunk and bilateral shoulders, respectively, in vaginal surgery.³¹ However, surgeons who stand while operating vaginally reported more discomfort in the bilateral wrists, thighs, and lower legs than those who operated while seated.³¹ This suggests a potential ergonomic advantage to the seated position for vaginal surgery. Chair height should be adjusted so the surgeon can look straight ahead with the neck in a neutral position.³² Surgeons should consider using a headlamp, as this may prevent repetitive awkward movements to adjust overhead lights.³² For standing surgery, the table height should be adjusted for the tallest surgeon, and shorter surgeons or assistants should use steps as needed.³

Surgical assistants should switch sides during the course of the case to avoid excessive unilateral upper-extremity strain.³² The addition of a table-mounted vaginal retractor system may be useful in relieving physical strain for surgical assistants, but data currently are lacking to demonstrate this ergonomic benefit.³³ Further studies are needed, especially since many surgeons take on the role of surgical assist in the teaching environment and subsequently report more WMSDs than their colleagues who do not work in teaching environments.^10,34

2. Pain relief from individual ergonomic positioning devices

Apart from adjusting how the OR equipment is arranged or how the surgeons adjust their positioning, several devices that assist with surgeon positioning—including gel mats or insoles, exoskeletons, and “augmented reality” glasses—are being studied.

The use of gel mats or insoles in the OR has mixed evidence in the literature.^35-37

Exoskeletons, external devices that support a surgeon’s posture and positioning, have been studied thus far in simulated nonsterile surgical environments. Preliminarily, it appears that use of an exoskeleton can decrease muscle activity and time spent in static positions, with a reported decrease in post-task user discomfort.^38,39 More data are needed to determine if exoskeletons can be used in the sterile setting and for longer durations as may occur in actual OR cases.

Augmented reality glasses project the laparoscopic monitor image to the glasses, which frees the surgeon to place the “monitor” in a more neutral, ergonomic position. In one study, use of augmented reality glasses was associated with decreased muscle activity and a reduction in Rapid Entire Body Assessment (REBA) scores when compared with use of the conventional laparoscopic monitor.⁴⁰More data are needed on these emerging technologies to determine whether adverse effects occur with prolonged use.

Continue to: 3. Implementing intraoperative microbreaks and stretching...

The American College of Surgeons (ACS) recommends that surgeons avoid prolonged static postures during procedures.²⁸ One strategy for preventing sustained positioning is to incorporate breaks with associated stretching routinely during surgery.²⁸

Microbreaks. In a landmark study by Park and colleagues in 2017, 120-second long targeted stretching microbreaks (TSMBs) were completed every 20 to 40 minutes during a surgery, and results demonstrated improved postoperative surgeon pain scores without an associated increase in the length of the case.⁴¹ These surgeons reported improved pain in the neck, bilateral shoulders, bilateral hands, and lower back. Eighty-eight percent of surgeons reported either improvement or “no change” in their mental focus, and 100% reported improvement or “no change” in their physical performance after TSMBs were implemented.⁴² Of surveyed surgeons, 87% wanted TSMBs incorporated routinely.^41,42

Stretches. Multiple resources, such as the ACS and the Mayo Clinic, for intraoperative stretches are available. The ACS recommends performing neck and shoulder stretches during intraoperative microbreaks, including a range-of-movement neck exercise, deep cervical flexor training, and standing scapular retraction.²⁸ The ACS also demonstrates lumbrical stretches for the fingers and passive wrist extension exercises to be used intraoperatively (or between cases) (FIGURE 1).²⁸ The Mayo Clinic Hallbeck Human Factors Engineering Laboratories has a publicly available “OR Stretch Instructional Video” in which the surgeon is guided through several different short stretches, including shoulder shrugging and side bends, that can be used during surgery.⁴³

Both the ACS and the Mayo Clinic provide examples of pertinent stretch exercises for use when not in the sterile environment, between cases or after cases are complete. The ACS recommends several neck and shoulder stretches for the trapezius, levator scapulae, and pectoralis and recommends the use of a foam roller to improve thoracic mobility (FIGURE 2).²⁸ As above, the Mayo Clinic Hallbeck Human Factors Engineering Laboratories has a publicly available “OR-Stretch Between Surgery Stretches Video” in which the surgeon is guided through several short stretches that are done in a seated position, including stretches for the hamstring, lower back, and arms (FIGURE 3).⁴³

Many of the above-mentioned stretches were designed for use in the context of open, laparoscopic, or robotic surgery. For the vaginal surgeon, the intraoperative ergonomic stressors differ from those of other routes of surgery, and thus stretches tailored to the positioning during vaginal surgery are necessary. In a video recently published by the Society of Gynecologic Surgeons, several stretches are reviewed that target high-risk positions often held by the surgeon or assistant when operating vaginally.⁴⁴ These stretches include cervical retraction, thoracic extension, external arm rotation, cervical side bending, and lumbar extension (FIGURE 4).⁴⁴ The recommendation is to complete these exercises 2 times per day, with 8 to 10 repetitions per set.⁴⁴

Prioritizing ergonomic awareness and training

As caregivers, it is not uncommon for us to prioritize the needs of others before those of ourselves. However, WMSDs are prevalent, and their downstream effects may cause catastrophic professional and personal losses. Cumulatively, the global impact of WMSDs is a significant issue for the health care workforce and its longevity.

To prevent WMSDs, it is imperative that surgeons are aware of the factors that contribute to injury development and the appropriate, accessible modifications for these factors. While each surgical modality confers its own ergonomic challenges, these risks can be mitigated through increased awareness of OR setup, surgeon positioning, and incorporation of microbreaks and stretching exercises during and after surgical procedures.

Formal training in surgical ergonomics is lacking across specialties, including gynecology.⁴⁵ Multiple educational interventions have been proposed and studied to help fill this training gap.^30,46-49When used, these interventions have been associated with increased knowledge of surgical ergonomic principles or reduction in surgeon pain scores, including trainees.⁵⁰ As we become more cognizant of WMSDs, standardized resident curricula should be developed in an effort to reduce the prevalence of these potentially career-ending injuries.

In addition to education, cultivating a culture in which ergonomics is prioritized is essential. Although most surgeons report work-related pain, very few report their injuries to occupational health. For example, while 29% of gynecologic oncologists reported seeking treatment for a WMSD, only 1% had reported their injury to their employer.⁵ In a study of ACS members, only 19% of injuries were reported, 30% of surgeons stated that they did not know how to report an injury, and 21% felt that the resources for surgeons during and after an injury were inadequate.⁶

As we prioritize the health and safety of our patients, we also need to promote ergonomic awareness in the OR, respect the need for accommodations, encourage injury reporting, support surgeons who need to take time away for medical treatment, and partner with industry to develop new instruments and technology with effective ergonomic features. ●

The theme of the 49th Annual Scientific Meeting of the Society of Gynecologic Surgeons was Impact Factor—an allusion to scientific journal impact factor, as well as how we as gynecologic surgeons have a societal impact through our innovation, education, equity, and enterprise-level efforts. This theme and the diverse roster of speakers and presentations on contemporary and controversial issues impacting today’s gynecologic surgeons clearly resonated, breaking the prior registration record with more than 200 additional attendees than the previous year.

As always, the preconference postgraduate courses delivered relevant content that spanned the educational and surgical spectrum, including: “Innovations in training gynecologic surgeons”; “Urologic surgery for the gynecologic surgeon”; the social media workshop “Gynfluencing: Using social media to find your digital voice”; and “The sim factor: Making an impact in surgical education.” This also marked the first year of offering a specific SGS Fellows/Young Attendings’ course. The featured speaker of the SGS Equity Council was Patty Brisben, philanthropist, CEO, and founder of Pure Romance.

Dr. Beri Ridgeway, Cleveland Clinic Chief of Staff, delivered the Mark D. Walters Lecture, “Surgeon in the C-suite,” on leading approximately 5,000 physicians and the importance of surgeons and specifically ObGyns having a seat at the table. The TeLinde lecturer, Dr. Pam Moalli, Professor and Division Director for Urogynecology at the University of Pittsburgh Magee Womens Hospital, spoke on “Biomaterials for gynecologic surgeons: Toward bioinspired biomimetic devices.” The panel on the “Ergonomics of gynecologic surgery” was moderated by Dr. Amanda Fader and Dr. Kim Kho, who shared their experiences with work-related musculoskeletal injury, and featured esteemed panelists Dr. Noor Abu-Alnadi from UNC, Dr. Sue Hallbeck from Mayo Clinic, and Dr. Ladin Yurteri-Kaplan from Columbia University.

The conference also featured a new format of Ted Med Talks:

• Dr. Jason Wright, Editor-in-Chief, Obstetrics & Gynecology, and Division Director of Gynecologic Oncology at Columbia University, who spoke on “Surgical volume and outcomes for gynecologic surgery: Is more always better?”
• Dr. Kelly Wright, Division Director, Minimally Invasive Gynecologic Surgery, Cedars Sinai, on “Climate change starts at 7:15”
• Dr. Ebony Carter, Associate Editor, Equity, Obstetrics & Gynecology, and Division Director, Maternal Fetal Medicine, Washington University, on “Centering equity in reproductive health research.”

In this special section, several of these talks are presented. Additionally, Dr. Laura Homewood and her coauthors will discuss gender and racial biases in a large multi-institutional sample of more than 15,000 Press Ganey patient satisfaction surveys.

Dr. Cheryl Iglesia, SGS former president, and I hope that you will consider attending #SGS2024 in Orlando, Florida, led by Dr. Suzie As-Sanie, program chair, and Dr. Rosanne Kho, current SGS president, which promises to be another exciting meeting. ●

The theme of the 49th Annual Scientific Meeting of the Society of Gynecologic Surgeons was Impact Factor—an allusion to scientific journal impact factor, as well as how we as gynecologic surgeons have a societal impact through our innovation, education, equity, and enterprise-level efforts. This theme and the diverse roster of speakers and presentations on contemporary and controversial issues impacting today’s gynecologic surgeons clearly resonated, breaking the prior registration record with more than 200 additional attendees than the previous year.

As always, the preconference postgraduate courses delivered relevant content that spanned the educational and surgical spectrum, including: “Innovations in training gynecologic surgeons”; “Urologic surgery for the gynecologic surgeon”; the social media workshop “Gynfluencing: Using social media to find your digital voice”; and “The sim factor: Making an impact in surgical education.” This also marked the first year of offering a specific SGS Fellows/Young Attendings’ course. The featured speaker of the SGS Equity Council was Patty Brisben, philanthropist, CEO, and founder of Pure Romance.

Dr. Beri Ridgeway, Cleveland Clinic Chief of Staff, delivered the Mark D. Walters Lecture, “Surgeon in the C-suite,” on leading approximately 5,000 physicians and the importance of surgeons and specifically ObGyns having a seat at the table. The TeLinde lecturer, Dr. Pam Moalli, Professor and Division Director for Urogynecology at the University of Pittsburgh Magee Womens Hospital, spoke on “Biomaterials for gynecologic surgeons: Toward bioinspired biomimetic devices.” The panel on the “Ergonomics of gynecologic surgery” was moderated by Dr. Amanda Fader and Dr. Kim Kho, who shared their experiences with work-related musculoskeletal injury, and featured esteemed panelists Dr. Noor Abu-Alnadi from UNC, Dr. Sue Hallbeck from Mayo Clinic, and Dr. Ladin Yurteri-Kaplan from Columbia University.

The conference also featured a new format of Ted Med Talks:

• Dr. Jason Wright, Editor-in-Chief, Obstetrics & Gynecology, and Division Director of Gynecologic Oncology at Columbia University, who spoke on “Surgical volume and outcomes for gynecologic surgery: Is more always better?”
• Dr. Kelly Wright, Division Director, Minimally Invasive Gynecologic Surgery, Cedars Sinai, on “Climate change starts at 7:15”
• Dr. Ebony Carter, Associate Editor, Equity, Obstetrics & Gynecology, and Division Director, Maternal Fetal Medicine, Washington University, on “Centering equity in reproductive health research.”

In this special section, several of these talks are presented. Additionally, Dr. Laura Homewood and her coauthors will discuss gender and racial biases in a large multi-institutional sample of more than 15,000 Press Ganey patient satisfaction surveys.

Dr. Cheryl Iglesia, SGS former president, and I hope that you will consider attending #SGS2024 in Orlando, Florida, led by Dr. Suzie As-Sanie, program chair, and Dr. Rosanne Kho, current SGS president, which promises to be another exciting meeting. ●

The theme of the 49th Annual Scientific Meeting of the Society of Gynecologic Surgeons was Impact Factor—an allusion to scientific journal impact factor, as well as how we as gynecologic surgeons have a societal impact through our innovation, education, equity, and enterprise-level efforts. This theme and the diverse roster of speakers and presentations on contemporary and controversial issues impacting today’s gynecologic surgeons clearly resonated, breaking the prior registration record with more than 200 additional attendees than the previous year.

As always, the preconference postgraduate courses delivered relevant content that spanned the educational and surgical spectrum, including: “Innovations in training gynecologic surgeons”; “Urologic surgery for the gynecologic surgeon”; the social media workshop “Gynfluencing: Using social media to find your digital voice”; and “The sim factor: Making an impact in surgical education.” This also marked the first year of offering a specific SGS Fellows/Young Attendings’ course. The featured speaker of the SGS Equity Council was Patty Brisben, philanthropist, CEO, and founder of Pure Romance.

Dr. Beri Ridgeway, Cleveland Clinic Chief of Staff, delivered the Mark D. Walters Lecture, “Surgeon in the C-suite,” on leading approximately 5,000 physicians and the importance of surgeons and specifically ObGyns having a seat at the table. The TeLinde lecturer, Dr. Pam Moalli, Professor and Division Director for Urogynecology at the University of Pittsburgh Magee Womens Hospital, spoke on “Biomaterials for gynecologic surgeons: Toward bioinspired biomimetic devices.” The panel on the “Ergonomics of gynecologic surgery” was moderated by Dr. Amanda Fader and Dr. Kim Kho, who shared their experiences with work-related musculoskeletal injury, and featured esteemed panelists Dr. Noor Abu-Alnadi from UNC, Dr. Sue Hallbeck from Mayo Clinic, and Dr. Ladin Yurteri-Kaplan from Columbia University.

The conference also featured a new format of Ted Med Talks:

• Dr. Jason Wright, Editor-in-Chief, Obstetrics & Gynecology, and Division Director of Gynecologic Oncology at Columbia University, who spoke on “Surgical volume and outcomes for gynecologic surgery: Is more always better?”
• Dr. Kelly Wright, Division Director, Minimally Invasive Gynecologic Surgery, Cedars Sinai, on “Climate change starts at 7:15”
• Dr. Ebony Carter, Associate Editor, Equity, Obstetrics & Gynecology, and Division Director, Maternal Fetal Medicine, Washington University, on “Centering equity in reproductive health research.”

In this special section, several of these talks are presented. Additionally, Dr. Laura Homewood and her coauthors will discuss gender and racial biases in a large multi-institutional sample of more than 15,000 Press Ganey patient satisfaction surveys.

Dr. Cheryl Iglesia, SGS former president, and I hope that you will consider attending #SGS2024 in Orlando, Florida, led by Dr. Suzie As-Sanie, program chair, and Dr. Rosanne Kho, current SGS president, which promises to be another exciting meeting. ●

Climate change has been called the biggest health threat of the 21st century.¹ The health care sector is a huge contributor to global carbon emissions, accounting for almost double the emissions of global aviation. While other industries and countries are implementing mitigation measures to decrease their emissions, health care is currently on track to double its carbon emissions by 2050, even though it should be carbon neutral by that time to comply with the Paris Climate Agreement.² There have been some national efforts to curb health care emissions, including the creation of the Office of Climate Change and Health Equity in 2021 and the passage of the Inflation Reduction Act in 2022.³ These are top-down, administrative approaches, and to be successful we will also need clinicians to understand and address this problem.

The negative impacts of heat, air pollution, and exposure to toxic substances on human health have been well documented in multiple regions across multiple specialties.^4-7 The United States makes up 27% of the global health care carbon footprint—more emissions than the entire United Kingdom as a country—despite having only 4% of the world’s population.² Culture and incentives for an overabundance of single-use supplies, not evidence for patient safety, have led to this uniquely American problem. It is evident that our health care industry is an excellent place to implement mitigation measures for carbon emissions that contribute to climate change and can improve health outcomes.

In this article, we recommend 10 practices that can decrease our carbon footprint in ObGyn. We focus on the classic motto of “Reduce, Reuse, Recycle,” while adding “Remove” and “Reimagine” to classify the ways in which we can reduce emissions while not compromising our care to patients.

Reduce

1. Minimize opened materials and single-use devices in the OR and labor and delivery

Health care is a unique setting where a culture of infection prevention and efficiency has led low-cost, single-use supplies to dominate over reusable items. While single-use items can have inexpensive purchasing costs compared to reusable items, the environmental costs required for the production and disposal of the former are often much greater. In operating rooms (ORs) and labor and delivery (LD) units, single-use items are omnipresent. Over the past decade, researchers and clinicians have started to take a closer look at these items and their carbon footprint. One group evaluated hysterectomy through a waste audit and found that the vast majority of waste from all of the cases was Spunbond Meltblown Spunbond, or SMS; plastic materialthat comprises gowns; blue wraps; and drapes; followed by hard plastic material that comprises trays and packaging.⁸ Moreover, production and manufacturing processes contributed to 95% of the environmental impacts of these items.⁸

In an effort to be time efficient, OR staff will open sterile surgical packs and individual peel-pack items prior to surgery to minimize having to find items during surgery. However, this creates an inordinate amount of waste. One group of neurosurgeons who evaluated their opened but unused supplies found that 85% of their unused items were individually opened items, leading to a waste of $2.9 million per year.⁹ Minor procedures like dilation and curettage, cystoscopy, and hysteroscopy do not need such a large sterile field, as these procedures are also safe to perform in the office. Hand surgeons have been quick to lead in this space, particularly with minor procedures such as carpal tunnel release. One division was able to eliminate 2.8 tons of waste and save $13,000 in a 2-year period by reducing the sterile field.¹⁰ ObGyns can work with OR and LD staff to create custom packs that minimize unused or underutilized items, helping to reduce both the carbon footprint and health care spending.

Bottom line: ObGyns can help foster a culture of having supplies available but not opened until needed during a case.

Continue to: 2. Decrease regulated medical waste...

Health care is unique from other fields in that there are multiple waste streams to consider. Infectious waste and items saturated in blood or capable of causing infection must be placed into regulated medical waste (RMW), or more commonly, red biohazard bags. RMW is autoclaved or incinerated prior to disposal in a landfill. This process is more financially and environmentally costly than general municipal waste (GMW). This process also requires more transport—1 study revealed that GMW traveled 20 km to a landfill for disposal, compared with the 50 km that RMW traveled for sterilized-prior-to-landfill disposal.¹¹

Unfortunately, the vast majority of items placed in RMW are incorrectly triaged and should instead be disposed in GMW.^12,13 One study performed in an emergency department revealed that 85% of waste was incorrectly placed in the RMW.¹²

Bottom line: ObGyns can avoid placing items in RMW that may not qualify and advocate for institution policy changes to remove RMW from places such as waiting rooms, at the patient bedside, or next to scrub sinks.

3. Reduce energy use

ORs and LD units use a lot of energy, and numerous studies have demonstrated that the heating, ventilation, and air conditioning (HVAC) system plays a large role in emissions.^8,11 This can easily be fixed by “HVAC setbacks” and powering down rooms when not in use. One institution powered down ORs when not in use and reduced 234 metric tons of CO₂ emissions and saved $33,000 per year.¹⁴ Transitioning to light-emitting diode (LED) lights reduced energy usage at 1 institution by almost 50%.¹⁵ Finally, computers in clinical offices, examination rooms, and administrative offices can be powered down at the end of the day. One study found that in 1 radiology department, 29 computers left on overnight and on weekends emitted 17.7 tons of CO₂ emissions in 1 year.¹⁶

Bottom line: We as ObGyns can advocate for how energy can be saved outside of surgical cases, including powering down ORs and LD units, transitioning to LED lighting, and powering down workstations.

Reuse

4. Choose reusable equipment

In ObGyn practice, the most commonly used tool is the speculum. Given its omnipresence, the speculum is a great place to start to decrease our carbon footprint. Two studies have evaluated the environmental impact of reusable versus single-use disposable specula, and both demonstrated that the stainless-steel versions have less global warming potential than the acrylic varieties.^17,18 Donahue and colleagues¹⁷ demonstrated that it only took 2 to 3 pelvic examinations for the cost of stainless-steel specula to break even, even when sterilized in a half-filled autoclave tray. Rodriquez, et al¹⁸ revealed that, compared with an acrylic model, the stainless-steel specula had fewer negative impacts in terms of global warming, acidification, respiratory effects, smog, and fossil fuel depletion.¹⁸

Bottom line: Strongly consider using stainless-steel specula to reduce costs and carbon emissions.

In addition to specula, ObGyns can choose reusable equipment in the OR. For example, surgeons can use stainless-steel trocars instead of disposable trocars.¹⁹ In vaginal cases, Breisky-Navratil retractors can be used instead of disposable self-retaining retractors. Plastic basins that often are included in sterile supply packs can be replaced with stainless-steel basins, which could have profound positive effects on the carbon footprint of gynecologic surgery.⁸ One study of ObGyns demonstrated that 95% of physicians supported waste-reduction efforts, and 66% supported utilizing reusable surgical tools instead of disposable tools.²⁰

Bottom line: As surgeons, ObGyns have influence over what they want to use in the OR, and they can petition for reusable options over disposable options.

5. Launder the sterile blue towels

Sterile blue towels, which are made of cotton, have the largest environmental footprint compared with other disposable materials, such as plastics, and contribute greatly to toxicity in human health.^8,11 Although these towels cannot be laundered and sterilized again for use in a sterile surgical field, they can be laundered and repurposed, including by environmental services to clean hospital rooms. Blue towels should be able to be laundered no matter how saturated in body fluids they are.

Bottom line: ObGyns should strive to always launder the blue towels and educate trainees and other staff in the OR to do the same.

Recycle

6. Recycle and reprocess materials and devices

While recycling is immensely important, it requires a large amount of energy to break down a material to its raw components for manufacturing. It likely reduces our carbon footprint from OR procedures by only 5%.⁸ However, recycling is still a good way to divert appropriate materials from landfill, saving costs and emissions at the end of a material’s life. One example is sterile blue wrap, which is a petroleum product with a recycling number of 6 and a filtration rating of N99. Blue wrap can be recycled into plastic pellets, or it can be recreated into other hospital supplies, such as gowns.

Bottom line: ObGyns can petition their hospitals to work with suppliers and waste-processing companies who have recycling programs built into their supply chains.

By contrast, reprocessing can have a much larger impact on carbon emissions. Complex items, such as advanced energy devices that can be reprocessed, result in a greater reduction in carbon emissions due to the reuse of their complex materials and manufacturing when compared with such devices that cannot be reprocessed. Recycling and reprocessing programs are already in place for several devices (TABLE). Authors of a systematic review showed that there is no evidence to support the use of single-use supplies and instruments over reprocessed items when considering instrument function, ease of use, patient safety, transmission of infection, or long-term patient outcomes.²¹

Bottom line: ObGyns can choose to use reprocessed items in ORs instead of single-use devices and educate staff on the safety of these items.

Continue to: Remove...

7. Remove desflurane and other volatile gases from formularies

Volatile anesthetic gases, such as desflurane, isoflurane, and nitrous oxide, are themselves potent greenhouse gases, comprising a large portion of the carbon emissions that come from the OR.²² Desflurane was developed to have a rapid onset for induction and quick recovery; however, studies have shown no clinical benefit over other gases.²³ Furthermore, the costs and greenhouse gas potential are substantial. Desflurane costs 2 to 3 times more and has more than 20 times the global warming potential of the other volatile gases (FIGURE).⁸ Using 1 hour of desflurane is equivalent to driving 378 miles in a gas-powered vehicle, while the use of isoflurane and sevoflurane create equivalents of only 15 and 8 miles, respectively.²³

Nitrous oxide is another powerful greenhouse gas that is a direct ozone depletor and can stay in the atmosphere for 114 years.²² Nitrous oxide has limited clinical use in hospitals, but it is often stored in central hospital piping. Most of the impact of nitrous oxide comes through leaks in a poor system design rather than patient delivery. One estimate reveals that more than 13 million liters of nitrous oxide are lost annually from leaks in European hospitals.²² The American Society of Anesthesiologists recommends decommissioning central piping of nitrous oxide in favor of cylinders at the point of care.²⁴

Literature on enhanced recovery after surgery in gynecology promotes the use of propofol over volatile gases for our patients because of the high rate of postoperative nausea and vomiting seen with gases.²⁵ Volatile gases should be a last-choice anesthetic for our patients.

Bottom line: It is critical that ObGyns work with colleagues in anesthesia to develop climate- and patient-friendly protocols for procedures.

8. Remove endocrine-disrupting chemicals from clinical supplies

Endocrine-disrupting chemicals (EDCs) are a type of chemical that alter the hormonal systems of humans, which can result in adverse health effects. Multiple studies and reviews have tied EDCs to reproductive abnormalities, such as the effects of bisphenol A (BPA) on estradiol levels, antral follicle counts, oocyte quality, and implantation rates; phthalates on fibroid burden; triclosan on embryo quality; parabens on live birth rates; and perfluoroalkylsubstances (PFAS or “forever substances”) on hypertensive disorders of pregnancy.^5,26,27

What might be most shocking is that these EDCs are incorporated into medical supplies and pharmaceuticals. For example, BPA is known to line dialysis and ointment tubes, parabens are used for their antimicrobial properties in ultrasound gel and hep-locks, and phthalates are found in up to 40% of medical-use plastics and controlled-release medications. Authors of an observational study found that 74% of patients admitted to an LD unit were exposed to EDCs. In a neonatal intensive care unit (NICU), most of the supplies contained an EDC, and urinary BPA levels were elevated in neonates admitted to a NICU, raising concerns about long-term health risks.⁵

Bottom line: Physicians and health care institutions have an obligation to petition industry partners and suppliers to remove EDCs from their supply chains.

Reimagine

9. Educate

The field of health care sustainability remains in its infancy, but from 2007 to 2019, publications on climate change and health in academia increased by a factor of 8.²⁹ Additionally, through waste audits, quality-improvement projects, and life cycle analyses (analytical tools to evaluate product or process emissions from materials extraction to disposal), we have gained insight into the scope of the problem, with evidence showing that our practices are largely derived from culture. It is time to provide formal education on health care sustainability to medical trainees, staff, and clinicians alike, who desire to see this topic reflected in their formal curricula.³⁰ Start talking about it!

Bottom line: Commentaries, webinars, formal didactics sessions, in-services, and hospital workgroups to introduce this topic are a good way to teach others about the carbon footprint of our care and solutions to minimize it.

10. Engage in advocacy

Physicians have an ethical duty to advocate for change at the local, regional, and national levels if we want to see a better future for our patients, their children, and even ourselves. We should reimagine this work as an important public health initiative.³¹ Surveys of physicians, including ObGyns, reveal a concern about the sustainability of health care and a commitment to addressing this issue.²⁰ ObGyns are on the frontlines of delivering care every day, so we are poised to implement changes that can impact our patients, especially when we can lead and petition hospital or local committees.^20,28,32 There is much to be done, but every voice counts and can make impactful changes at every level. ●

Climate change has been called the biggest health threat of the 21st century.¹ The health care sector is a huge contributor to global carbon emissions, accounting for almost double the emissions of global aviation. While other industries and countries are implementing mitigation measures to decrease their emissions, health care is currently on track to double its carbon emissions by 2050, even though it should be carbon neutral by that time to comply with the Paris Climate Agreement.² There have been some national efforts to curb health care emissions, including the creation of the Office of Climate Change and Health Equity in 2021 and the passage of the Inflation Reduction Act in 2022.³ These are top-down, administrative approaches, and to be successful we will also need clinicians to understand and address this problem.

The negative impacts of heat, air pollution, and exposure to toxic substances on human health have been well documented in multiple regions across multiple specialties.^4-7 The United States makes up 27% of the global health care carbon footprint—more emissions than the entire United Kingdom as a country—despite having only 4% of the world’s population.² Culture and incentives for an overabundance of single-use supplies, not evidence for patient safety, have led to this uniquely American problem. It is evident that our health care industry is an excellent place to implement mitigation measures for carbon emissions that contribute to climate change and can improve health outcomes.

In this article, we recommend 10 practices that can decrease our carbon footprint in ObGyn. We focus on the classic motto of “Reduce, Reuse, Recycle,” while adding “Remove” and “Reimagine” to classify the ways in which we can reduce emissions while not compromising our care to patients.

Reduce

1. Minimize opened materials and single-use devices in the OR and labor and delivery

Health care is a unique setting where a culture of infection prevention and efficiency has led low-cost, single-use supplies to dominate over reusable items. While single-use items can have inexpensive purchasing costs compared to reusable items, the environmental costs required for the production and disposal of the former are often much greater. In operating rooms (ORs) and labor and delivery (LD) units, single-use items are omnipresent. Over the past decade, researchers and clinicians have started to take a closer look at these items and their carbon footprint. One group evaluated hysterectomy through a waste audit and found that the vast majority of waste from all of the cases was Spunbond Meltblown Spunbond, or SMS; plastic materialthat comprises gowns; blue wraps; and drapes; followed by hard plastic material that comprises trays and packaging.⁸ Moreover, production and manufacturing processes contributed to 95% of the environmental impacts of these items.⁸

In an effort to be time efficient, OR staff will open sterile surgical packs and individual peel-pack items prior to surgery to minimize having to find items during surgery. However, this creates an inordinate amount of waste. One group of neurosurgeons who evaluated their opened but unused supplies found that 85% of their unused items were individually opened items, leading to a waste of $2.9 million per year.⁹ Minor procedures like dilation and curettage, cystoscopy, and hysteroscopy do not need such a large sterile field, as these procedures are also safe to perform in the office. Hand surgeons have been quick to lead in this space, particularly with minor procedures such as carpal tunnel release. One division was able to eliminate 2.8 tons of waste and save $13,000 in a 2-year period by reducing the sterile field.¹⁰ ObGyns can work with OR and LD staff to create custom packs that minimize unused or underutilized items, helping to reduce both the carbon footprint and health care spending.

Bottom line: ObGyns can help foster a culture of having supplies available but not opened until needed during a case.

Continue to: 2. Decrease regulated medical waste...

Health care is unique from other fields in that there are multiple waste streams to consider. Infectious waste and items saturated in blood or capable of causing infection must be placed into regulated medical waste (RMW), or more commonly, red biohazard bags. RMW is autoclaved or incinerated prior to disposal in a landfill. This process is more financially and environmentally costly than general municipal waste (GMW). This process also requires more transport—1 study revealed that GMW traveled 20 km to a landfill for disposal, compared with the 50 km that RMW traveled for sterilized-prior-to-landfill disposal.¹¹

Unfortunately, the vast majority of items placed in RMW are incorrectly triaged and should instead be disposed in GMW.^12,13 One study performed in an emergency department revealed that 85% of waste was incorrectly placed in the RMW.¹²

Bottom line: ObGyns can avoid placing items in RMW that may not qualify and advocate for institution policy changes to remove RMW from places such as waiting rooms, at the patient bedside, or next to scrub sinks.

3. Reduce energy use

ORs and LD units use a lot of energy, and numerous studies have demonstrated that the heating, ventilation, and air conditioning (HVAC) system plays a large role in emissions.^8,11 This can easily be fixed by “HVAC setbacks” and powering down rooms when not in use. One institution powered down ORs when not in use and reduced 234 metric tons of CO₂ emissions and saved $33,000 per year.¹⁴ Transitioning to light-emitting diode (LED) lights reduced energy usage at 1 institution by almost 50%.¹⁵ Finally, computers in clinical offices, examination rooms, and administrative offices can be powered down at the end of the day. One study found that in 1 radiology department, 29 computers left on overnight and on weekends emitted 17.7 tons of CO₂ emissions in 1 year.¹⁶

Bottom line: We as ObGyns can advocate for how energy can be saved outside of surgical cases, including powering down ORs and LD units, transitioning to LED lighting, and powering down workstations.

Reuse

4. Choose reusable equipment

In ObGyn practice, the most commonly used tool is the speculum. Given its omnipresence, the speculum is a great place to start to decrease our carbon footprint. Two studies have evaluated the environmental impact of reusable versus single-use disposable specula, and both demonstrated that the stainless-steel versions have less global warming potential than the acrylic varieties.^17,18 Donahue and colleagues¹⁷ demonstrated that it only took 2 to 3 pelvic examinations for the cost of stainless-steel specula to break even, even when sterilized in a half-filled autoclave tray. Rodriquez, et al¹⁸ revealed that, compared with an acrylic model, the stainless-steel specula had fewer negative impacts in terms of global warming, acidification, respiratory effects, smog, and fossil fuel depletion.¹⁸

Bottom line: Strongly consider using stainless-steel specula to reduce costs and carbon emissions.

In addition to specula, ObGyns can choose reusable equipment in the OR. For example, surgeons can use stainless-steel trocars instead of disposable trocars.¹⁹ In vaginal cases, Breisky-Navratil retractors can be used instead of disposable self-retaining retractors. Plastic basins that often are included in sterile supply packs can be replaced with stainless-steel basins, which could have profound positive effects on the carbon footprint of gynecologic surgery.⁸ One study of ObGyns demonstrated that 95% of physicians supported waste-reduction efforts, and 66% supported utilizing reusable surgical tools instead of disposable tools.²⁰

Bottom line: As surgeons, ObGyns have influence over what they want to use in the OR, and they can petition for reusable options over disposable options.

5. Launder the sterile blue towels

Sterile blue towels, which are made of cotton, have the largest environmental footprint compared with other disposable materials, such as plastics, and contribute greatly to toxicity in human health.^8,11 Although these towels cannot be laundered and sterilized again for use in a sterile surgical field, they can be laundered and repurposed, including by environmental services to clean hospital rooms. Blue towels should be able to be laundered no matter how saturated in body fluids they are.

Bottom line: ObGyns should strive to always launder the blue towels and educate trainees and other staff in the OR to do the same.

Recycle

6. Recycle and reprocess materials and devices

While recycling is immensely important, it requires a large amount of energy to break down a material to its raw components for manufacturing. It likely reduces our carbon footprint from OR procedures by only 5%.⁸ However, recycling is still a good way to divert appropriate materials from landfill, saving costs and emissions at the end of a material’s life. One example is sterile blue wrap, which is a petroleum product with a recycling number of 6 and a filtration rating of N99. Blue wrap can be recycled into plastic pellets, or it can be recreated into other hospital supplies, such as gowns.

Bottom line: ObGyns can petition their hospitals to work with suppliers and waste-processing companies who have recycling programs built into their supply chains.

By contrast, reprocessing can have a much larger impact on carbon emissions. Complex items, such as advanced energy devices that can be reprocessed, result in a greater reduction in carbon emissions due to the reuse of their complex materials and manufacturing when compared with such devices that cannot be reprocessed. Recycling and reprocessing programs are already in place for several devices (TABLE). Authors of a systematic review showed that there is no evidence to support the use of single-use supplies and instruments over reprocessed items when considering instrument function, ease of use, patient safety, transmission of infection, or long-term patient outcomes.²¹

Bottom line: ObGyns can choose to use reprocessed items in ORs instead of single-use devices and educate staff on the safety of these items.

Continue to: Remove...

7. Remove desflurane and other volatile gases from formularies

Volatile anesthetic gases, such as desflurane, isoflurane, and nitrous oxide, are themselves potent greenhouse gases, comprising a large portion of the carbon emissions that come from the OR.²² Desflurane was developed to have a rapid onset for induction and quick recovery; however, studies have shown no clinical benefit over other gases.²³ Furthermore, the costs and greenhouse gas potential are substantial. Desflurane costs 2 to 3 times more and has more than 20 times the global warming potential of the other volatile gases (FIGURE).⁸ Using 1 hour of desflurane is equivalent to driving 378 miles in a gas-powered vehicle, while the use of isoflurane and sevoflurane create equivalents of only 15 and 8 miles, respectively.²³

Nitrous oxide is another powerful greenhouse gas that is a direct ozone depletor and can stay in the atmosphere for 114 years.²² Nitrous oxide has limited clinical use in hospitals, but it is often stored in central hospital piping. Most of the impact of nitrous oxide comes through leaks in a poor system design rather than patient delivery. One estimate reveals that more than 13 million liters of nitrous oxide are lost annually from leaks in European hospitals.²² The American Society of Anesthesiologists recommends decommissioning central piping of nitrous oxide in favor of cylinders at the point of care.²⁴

Literature on enhanced recovery after surgery in gynecology promotes the use of propofol over volatile gases for our patients because of the high rate of postoperative nausea and vomiting seen with gases.²⁵ Volatile gases should be a last-choice anesthetic for our patients.

Bottom line: It is critical that ObGyns work with colleagues in anesthesia to develop climate- and patient-friendly protocols for procedures.

8. Remove endocrine-disrupting chemicals from clinical supplies

Endocrine-disrupting chemicals (EDCs) are a type of chemical that alter the hormonal systems of humans, which can result in adverse health effects. Multiple studies and reviews have tied EDCs to reproductive abnormalities, such as the effects of bisphenol A (BPA) on estradiol levels, antral follicle counts, oocyte quality, and implantation rates; phthalates on fibroid burden; triclosan on embryo quality; parabens on live birth rates; and perfluoroalkylsubstances (PFAS or “forever substances”) on hypertensive disorders of pregnancy.^5,26,27

What might be most shocking is that these EDCs are incorporated into medical supplies and pharmaceuticals. For example, BPA is known to line dialysis and ointment tubes, parabens are used for their antimicrobial properties in ultrasound gel and hep-locks, and phthalates are found in up to 40% of medical-use plastics and controlled-release medications. Authors of an observational study found that 74% of patients admitted to an LD unit were exposed to EDCs. In a neonatal intensive care unit (NICU), most of the supplies contained an EDC, and urinary BPA levels were elevated in neonates admitted to a NICU, raising concerns about long-term health risks.⁵

Bottom line: Physicians and health care institutions have an obligation to petition industry partners and suppliers to remove EDCs from their supply chains.

Reimagine

9. Educate

The field of health care sustainability remains in its infancy, but from 2007 to 2019, publications on climate change and health in academia increased by a factor of 8.²⁹ Additionally, through waste audits, quality-improvement projects, and life cycle analyses (analytical tools to evaluate product or process emissions from materials extraction to disposal), we have gained insight into the scope of the problem, with evidence showing that our practices are largely derived from culture. It is time to provide formal education on health care sustainability to medical trainees, staff, and clinicians alike, who desire to see this topic reflected in their formal curricula.³⁰ Start talking about it!

Bottom line: Commentaries, webinars, formal didactics sessions, in-services, and hospital workgroups to introduce this topic are a good way to teach others about the carbon footprint of our care and solutions to minimize it.

10. Engage in advocacy

Physicians have an ethical duty to advocate for change at the local, regional, and national levels if we want to see a better future for our patients, their children, and even ourselves. We should reimagine this work as an important public health initiative.³¹ Surveys of physicians, including ObGyns, reveal a concern about the sustainability of health care and a commitment to addressing this issue.²⁰ ObGyns are on the frontlines of delivering care every day, so we are poised to implement changes that can impact our patients, especially when we can lead and petition hospital or local committees.^20,28,32 There is much to be done, but every voice counts and can make impactful changes at every level. ●

Climate change has been called the biggest health threat of the 21st century.¹ The health care sector is a huge contributor to global carbon emissions, accounting for almost double the emissions of global aviation. While other industries and countries are implementing mitigation measures to decrease their emissions, health care is currently on track to double its carbon emissions by 2050, even though it should be carbon neutral by that time to comply with the Paris Climate Agreement.² There have been some national efforts to curb health care emissions, including the creation of the Office of Climate Change and Health Equity in 2021 and the passage of the Inflation Reduction Act in 2022.³ These are top-down, administrative approaches, and to be successful we will also need clinicians to understand and address this problem.

The negative impacts of heat, air pollution, and exposure to toxic substances on human health have been well documented in multiple regions across multiple specialties.^4-7 The United States makes up 27% of the global health care carbon footprint—more emissions than the entire United Kingdom as a country—despite having only 4% of the world’s population.² Culture and incentives for an overabundance of single-use supplies, not evidence for patient safety, have led to this uniquely American problem. It is evident that our health care industry is an excellent place to implement mitigation measures for carbon emissions that contribute to climate change and can improve health outcomes.

In this article, we recommend 10 practices that can decrease our carbon footprint in ObGyn. We focus on the classic motto of “Reduce, Reuse, Recycle,” while adding “Remove” and “Reimagine” to classify the ways in which we can reduce emissions while not compromising our care to patients.

Reduce

1. Minimize opened materials and single-use devices in the OR and labor and delivery

Health care is a unique setting where a culture of infection prevention and efficiency has led low-cost, single-use supplies to dominate over reusable items. While single-use items can have inexpensive purchasing costs compared to reusable items, the environmental costs required for the production and disposal of the former are often much greater. In operating rooms (ORs) and labor and delivery (LD) units, single-use items are omnipresent. Over the past decade, researchers and clinicians have started to take a closer look at these items and their carbon footprint. One group evaluated hysterectomy through a waste audit and found that the vast majority of waste from all of the cases was Spunbond Meltblown Spunbond, or SMS; plastic materialthat comprises gowns; blue wraps; and drapes; followed by hard plastic material that comprises trays and packaging.⁸ Moreover, production and manufacturing processes contributed to 95% of the environmental impacts of these items.⁸

In an effort to be time efficient, OR staff will open sterile surgical packs and individual peel-pack items prior to surgery to minimize having to find items during surgery. However, this creates an inordinate amount of waste. One group of neurosurgeons who evaluated their opened but unused supplies found that 85% of their unused items were individually opened items, leading to a waste of $2.9 million per year.⁹ Minor procedures like dilation and curettage, cystoscopy, and hysteroscopy do not need such a large sterile field, as these procedures are also safe to perform in the office. Hand surgeons have been quick to lead in this space, particularly with minor procedures such as carpal tunnel release. One division was able to eliminate 2.8 tons of waste and save $13,000 in a 2-year period by reducing the sterile field.¹⁰ ObGyns can work with OR and LD staff to create custom packs that minimize unused or underutilized items, helping to reduce both the carbon footprint and health care spending.

Bottom line: ObGyns can help foster a culture of having supplies available but not opened until needed during a case.

Continue to: 2. Decrease regulated medical waste...

Health care is unique from other fields in that there are multiple waste streams to consider. Infectious waste and items saturated in blood or capable of causing infection must be placed into regulated medical waste (RMW), or more commonly, red biohazard bags. RMW is autoclaved or incinerated prior to disposal in a landfill. This process is more financially and environmentally costly than general municipal waste (GMW). This process also requires more transport—1 study revealed that GMW traveled 20 km to a landfill for disposal, compared with the 50 km that RMW traveled for sterilized-prior-to-landfill disposal.¹¹

Unfortunately, the vast majority of items placed in RMW are incorrectly triaged and should instead be disposed in GMW.^12,13 One study performed in an emergency department revealed that 85% of waste was incorrectly placed in the RMW.¹²

Bottom line: ObGyns can avoid placing items in RMW that may not qualify and advocate for institution policy changes to remove RMW from places such as waiting rooms, at the patient bedside, or next to scrub sinks.

3. Reduce energy use

ORs and LD units use a lot of energy, and numerous studies have demonstrated that the heating, ventilation, and air conditioning (HVAC) system plays a large role in emissions.^8,11 This can easily be fixed by “HVAC setbacks” and powering down rooms when not in use. One institution powered down ORs when not in use and reduced 234 metric tons of CO₂ emissions and saved $33,000 per year.¹⁴ Transitioning to light-emitting diode (LED) lights reduced energy usage at 1 institution by almost 50%.¹⁵ Finally, computers in clinical offices, examination rooms, and administrative offices can be powered down at the end of the day. One study found that in 1 radiology department, 29 computers left on overnight and on weekends emitted 17.7 tons of CO₂ emissions in 1 year.¹⁶

Bottom line: We as ObGyns can advocate for how energy can be saved outside of surgical cases, including powering down ORs and LD units, transitioning to LED lighting, and powering down workstations.

Reuse

4. Choose reusable equipment

In ObGyn practice, the most commonly used tool is the speculum. Given its omnipresence, the speculum is a great place to start to decrease our carbon footprint. Two studies have evaluated the environmental impact of reusable versus single-use disposable specula, and both demonstrated that the stainless-steel versions have less global warming potential than the acrylic varieties.^17,18 Donahue and colleagues¹⁷ demonstrated that it only took 2 to 3 pelvic examinations for the cost of stainless-steel specula to break even, even when sterilized in a half-filled autoclave tray. Rodriquez, et al¹⁸ revealed that, compared with an acrylic model, the stainless-steel specula had fewer negative impacts in terms of global warming, acidification, respiratory effects, smog, and fossil fuel depletion.¹⁸

Bottom line: Strongly consider using stainless-steel specula to reduce costs and carbon emissions.

In addition to specula, ObGyns can choose reusable equipment in the OR. For example, surgeons can use stainless-steel trocars instead of disposable trocars.¹⁹ In vaginal cases, Breisky-Navratil retractors can be used instead of disposable self-retaining retractors. Plastic basins that often are included in sterile supply packs can be replaced with stainless-steel basins, which could have profound positive effects on the carbon footprint of gynecologic surgery.⁸ One study of ObGyns demonstrated that 95% of physicians supported waste-reduction efforts, and 66% supported utilizing reusable surgical tools instead of disposable tools.²⁰

Bottom line: As surgeons, ObGyns have influence over what they want to use in the OR, and they can petition for reusable options over disposable options.

5. Launder the sterile blue towels

Sterile blue towels, which are made of cotton, have the largest environmental footprint compared with other disposable materials, such as plastics, and contribute greatly to toxicity in human health.^8,11 Although these towels cannot be laundered and sterilized again for use in a sterile surgical field, they can be laundered and repurposed, including by environmental services to clean hospital rooms. Blue towels should be able to be laundered no matter how saturated in body fluids they are.

Bottom line: ObGyns should strive to always launder the blue towels and educate trainees and other staff in the OR to do the same.

Recycle

6. Recycle and reprocess materials and devices

While recycling is immensely important, it requires a large amount of energy to break down a material to its raw components for manufacturing. It likely reduces our carbon footprint from OR procedures by only 5%.⁸ However, recycling is still a good way to divert appropriate materials from landfill, saving costs and emissions at the end of a material’s life. One example is sterile blue wrap, which is a petroleum product with a recycling number of 6 and a filtration rating of N99. Blue wrap can be recycled into plastic pellets, or it can be recreated into other hospital supplies, such as gowns.

Bottom line: ObGyns can petition their hospitals to work with suppliers and waste-processing companies who have recycling programs built into their supply chains.

By contrast, reprocessing can have a much larger impact on carbon emissions. Complex items, such as advanced energy devices that can be reprocessed, result in a greater reduction in carbon emissions due to the reuse of their complex materials and manufacturing when compared with such devices that cannot be reprocessed. Recycling and reprocessing programs are already in place for several devices (TABLE). Authors of a systematic review showed that there is no evidence to support the use of single-use supplies and instruments over reprocessed items when considering instrument function, ease of use, patient safety, transmission of infection, or long-term patient outcomes.²¹

Bottom line: ObGyns can choose to use reprocessed items in ORs instead of single-use devices and educate staff on the safety of these items.

Continue to: Remove...

7. Remove desflurane and other volatile gases from formularies

Volatile anesthetic gases, such as desflurane, isoflurane, and nitrous oxide, are themselves potent greenhouse gases, comprising a large portion of the carbon emissions that come from the OR.²² Desflurane was developed to have a rapid onset for induction and quick recovery; however, studies have shown no clinical benefit over other gases.²³ Furthermore, the costs and greenhouse gas potential are substantial. Desflurane costs 2 to 3 times more and has more than 20 times the global warming potential of the other volatile gases (FIGURE).⁸ Using 1 hour of desflurane is equivalent to driving 378 miles in a gas-powered vehicle, while the use of isoflurane and sevoflurane create equivalents of only 15 and 8 miles, respectively.²³

Nitrous oxide is another powerful greenhouse gas that is a direct ozone depletor and can stay in the atmosphere for 114 years.²² Nitrous oxide has limited clinical use in hospitals, but it is often stored in central hospital piping. Most of the impact of nitrous oxide comes through leaks in a poor system design rather than patient delivery. One estimate reveals that more than 13 million liters of nitrous oxide are lost annually from leaks in European hospitals.²² The American Society of Anesthesiologists recommends decommissioning central piping of nitrous oxide in favor of cylinders at the point of care.²⁴

Literature on enhanced recovery after surgery in gynecology promotes the use of propofol over volatile gases for our patients because of the high rate of postoperative nausea and vomiting seen with gases.²⁵ Volatile gases should be a last-choice anesthetic for our patients.

Bottom line: It is critical that ObGyns work with colleagues in anesthesia to develop climate- and patient-friendly protocols for procedures.

8. Remove endocrine-disrupting chemicals from clinical supplies

Endocrine-disrupting chemicals (EDCs) are a type of chemical that alter the hormonal systems of humans, which can result in adverse health effects. Multiple studies and reviews have tied EDCs to reproductive abnormalities, such as the effects of bisphenol A (BPA) on estradiol levels, antral follicle counts, oocyte quality, and implantation rates; phthalates on fibroid burden; triclosan on embryo quality; parabens on live birth rates; and perfluoroalkylsubstances (PFAS or “forever substances”) on hypertensive disorders of pregnancy.^5,26,27

What might be most shocking is that these EDCs are incorporated into medical supplies and pharmaceuticals. For example, BPA is known to line dialysis and ointment tubes, parabens are used for their antimicrobial properties in ultrasound gel and hep-locks, and phthalates are found in up to 40% of medical-use plastics and controlled-release medications. Authors of an observational study found that 74% of patients admitted to an LD unit were exposed to EDCs. In a neonatal intensive care unit (NICU), most of the supplies contained an EDC, and urinary BPA levels were elevated in neonates admitted to a NICU, raising concerns about long-term health risks.⁵

Bottom line: Physicians and health care institutions have an obligation to petition industry partners and suppliers to remove EDCs from their supply chains.

Reimagine

9. Educate

The field of health care sustainability remains in its infancy, but from 2007 to 2019, publications on climate change and health in academia increased by a factor of 8.²⁹ Additionally, through waste audits, quality-improvement projects, and life cycle analyses (analytical tools to evaluate product or process emissions from materials extraction to disposal), we have gained insight into the scope of the problem, with evidence showing that our practices are largely derived from culture. It is time to provide formal education on health care sustainability to medical trainees, staff, and clinicians alike, who desire to see this topic reflected in their formal curricula.³⁰ Start talking about it!

Bottom line: Commentaries, webinars, formal didactics sessions, in-services, and hospital workgroups to introduce this topic are a good way to teach others about the carbon footprint of our care and solutions to minimize it.

10. Engage in advocacy

Physicians have an ethical duty to advocate for change at the local, regional, and national levels if we want to see a better future for our patients, their children, and even ourselves. We should reimagine this work as an important public health initiative.³¹ Surveys of physicians, including ObGyns, reveal a concern about the sustainability of health care and a commitment to addressing this issue.²⁰ ObGyns are on the frontlines of delivering care every day, so we are poised to implement changes that can impact our patients, especially when we can lead and petition hospital or local committees.^20,28,32 There is much to be done, but every voice counts and can make impactful changes at every level. ●

Wednesday, March 22. Day 4 of SGS.

Day 4, and the final day of the 49th SGS conference started with a sunrise run up and down the hills surrounding the JW Marriott Starr Resort. After breakfast, I entered the Tucson Ballroom to attend the last 2 scientific sessions of the conference.

Highlights from the first session included a look at postoperative outcomes and complication rates between gynecologic surgeons and general surgeons using the National Surgical Quality Improvement Program (NSQIP) database by Dr. Douglas Luchristt, who showed no difference between the 2 surgical specialties (and even better outcomes by gynecologists in certain operative measures), as well as the work of Dr. Christopher Hong who used 2 separate surgical databases (NSQIP and Michigan Surgical Quality Collaborative) to show that rates of vaginal hysterectomy have been decreasing from 2017 to 2020, even amongst patients who are likely good candidates for a vaginal route of hysterectomy. Dr. Jocelyn Fitzgerald presented her unique mixed methods research on how to better design the gynecologic office to improve the patient experience, using 3,000 Twitter responses to a question on this topic. Lastly, Dr. Emily Aldrich shared her work on better understanding the patient perception of same day discharge after major vaginal reconstructive surgery. An interesting finding of Dr. Aldrich’s study was that the most common response to her question about the “worst part of the surgical experience” was going home with a postoperative catheter, which surgeons often consider a small and temporary discomfort. The first session ended with the passing of the gavel from current SGS president Dr. Cheryl Iglesia, to the incoming SGS president Dr. Rosanne Kho, with much applause and excitement for what Dr. Kho will bring to the table in her new role.

The research presented at the final scientific session of the conference did not disappoint. A retrospective study on the influence of body mass index (BMI) on the time to surgical diagnosis of endometriosis by Dr. Melissa Markowitz found that obesity was associated with a delay of over 1 year in surgical diagnosis of endometriosis compared with normal and underweight patients. Dr. David (Ike) Rahn presented additional findings on his randomized, double-blinded, multicenter trial on perioperative use of vaginal estrogen cream in postmenopausal patients with prolapse. He found that 5 weeks of estrogen cream use was not associated with any improvement in urinary incontinence or sexual function.

Dr. Stephanie Glass Clark used the Premier Healthcare Database to show that that there was no difference in postoperative mesh exposure in patients who underwent a total hysterectomy compared with supracervical hysterectomy at the time of sacrocolpopexy. Dr. Kavita Mishra presented results from the FLOWER trial, which found no difference in postoperative outcomes for transgender women undergoing vaginoplasty for gender affirmation who did and did not undergo preoperative pelvic floor physical therapy. Finally, Dr. Carly Crowder shared her video of anatomy for sacral neuromodulation with some excellent cadaveric dissections to exhibit the peri-sacral and gluteal anatomy.

As the conference ended, raindrops pounded the sandy grounds of the resort as I waited in the lobby for my Uber to the airport. Dr. Rosanne Kho happened to walk by and stopped to speak with me and one of my attendings. She smiled as she asked about our experience at the conference and to wish us safe travels. To me, this moment embodies the spirit of mentorship and connection that is so unique to the SGS conference. I feel incredibly lucky to have met some of the physician leaders of our field, who genuinely want to get to know and help the next generation. This year’s meeting was attended by ObGyn generalists and surgeons of all gynecologic subspecialties and certainly met its goal in addressing topics with an “Impact Factor.” I am inspired by all the work that is happening across the country to move the needle and better our field. This was my first SGS experience, but it certainly won’t be the last. I hope you too will consider attending in the future!

Tuesday, March 21. Day 3 of SGS.

It’s Day 3 of the SGS conference! In addition to the academic roundtables, conference attendees had the option of doing early-morning yoga with Dr. Mireille Truong. Yoga sounded nice, but I spent the morning in bed, catching up on sleep. (My own version of wellness!) The scientific sessions of the day started at 7:30 am, and I especially want to highlight the work of Dr. Amy Askew who performed a randomized controlled trial comparing patient removal of urinary catheters placed for postoperative urinary retention to office removal. She found that patient urinary catheter removal was a feasible and safe option with excellent patient satisfaction and a reduction of in-person postoperative office visits. At the end of the session, Dr. Cheryl Iglesia gave her presidential address, where she shared her journey to becoming the physician, educator, researcher, and leader she is today. She emphasized the importance of being a continual learner and to give back by mentoring and educating the next generation. “Learn it, earn it, and return it.”

This was followed by the Te Linde lecture, given by Dr. Pamela Moalli. An exceptional surgeon-scientist, Dr. Moalli shared about her work on the impact of mesh on tissue, as well as alternative biologic options being developed, such as 3D printed membranes, extracellular matrix scaffolds, and living tissue grafts to create new ligamentous supports for the vagina. She discussed novel research using stem cell transplantation to harness the power of regeneration in the urethra or vagina following injury. I think it is safe to say that the entire room was in awe of the work she has done, and what she continues to do to find better therapeutic options for girls and women with pelvic floor disorders. Her talk ended in a standing ovation. Afterwards, all the University of Pittsburgh Medical Center-Magee Womens Hospital trainees, faculty, and several alumni took a picture with Dr. Moalli (fifth from the right in the picture).

Lunch followed, which included a brief walk around the industry exhibition hall. I then returned back to the Tucson Ballroom to listen in on the next scientific session on surgical ergonomics. Organized by Dr. Amy Park who herself suffered from work-related musculoskeletal injuries, the session was composed of an excellent video by Dr. Abby Stork on stretches to prevent and reduce the risk of surgeon-associated musculoskeletal injuries, especially in vaginal surgeons. There was then a panel of 3 experts, Dr. Noor Abu-Alnadi, Dr. Ladin Yurteri-Kaplan, and Dr. Susan Hallbeck (PhD ergonomics expert), moderated by Dr. Amanda Fader and Dr. Kimberly Kho. In particular, Dr. Hallbeck developed a timer app as a reminder for surgeons to stop every 40 minutes to stretch for 1.5 minutes (orstretch.mayoclinic.org). This has been studied and found to reduce musculoskeletal pain after surgery and improve physical performance without increasing total operating time. If you would like to see some of these between- and in-OR stretches yourself, an informative handout can be accessed at mcforms.mayo.edu.

Tuesday afternoon was left open. I joined Dr. Veronica Lerner, Dr. Kelly Wright, and Dr. Louise Perkins King on a 7.5-mile hike into the surrounding desert hills. We marveled at the many Saguaro cacti, some over 100 years old and towering many feet high, as well as the beautiful yellow, purple, and magenta flowers that were scattered among the desert brush. Several rabbits and deer wandered by us during our hike. On one of the trails, the stone skeleton of an old house stood, once a home to the Bowen family who had moved to Arizona for health reasons. I could see why they would want to move here—I felt such a peace looking at the gorgeous view from what was once their doorway.

After a shower and a lot of stretching, I got ready for the evening event, A Taste and Toast with SGS: Under the Arizona Skies. The food and drink were delicious, and I got to spend the evening catching up with a good friend. We watched as conference attendees assigned to different color teams (red, green, blue, and yellow), fought for the hallowed Golden Uterus Trophy in several competitive gynecology-themed games (eg, throwing sacral neuromodulation needle “darts” at balloons and removing small pom poms from a water bottle with a disposable operative hysteroscope). As the evening progressed, the DJ turned up the music and people made their way to the dance floor. The event served as a fundraiser for the SGS Pelvic Anatomy Group and successfully raised $35,000.

Day 2 of the SGS meeting started off with a gentle sunrise over the cacti-covered hills surrounding the JW Marriot Starr Pass Hotel, the venue for the 49th SGS annual scientific meeting. The first official event of the day after some engaging academic round tables was the recognition of the new SGS members. Much celebration was had over the 18 gynecologic surgeons who were inducted.

The second day included the first 3 scientific sessions of the conference. Some highlights include the work of Dr. Shawn Menefee on a randomized trial of sacral colpopexy, transvaginal mesh, and native tissue apical repair for posthysterectomy vault prolapse; a video by Dr. Matthew Fallon on a robotic-assisted laparoscopic approach to repairing a chronic uterine inversion; and the impact of age on regret following hysterectomy by Dr. Nathan King. Dr. Candace Parker-Autry also presented her work on the impact of perineorrhaphy on both female and male sexual function, and Dr. Cassie (Clarissa) Niino spoke elegantly on the “red bag problem” that exists in all of our operating rooms, which increases pollution and cost unnecessarily.

There were also several excellent talks given. Dr. Jason Wright spoke about the importance of surgical volume on gynecologic surgery. In particular, he noted that surgical volume needs to be considered not only at the surgeon level but also at the hospital level. Higher-volume hospitals will provide better care, in the same way that general, high-volume surgeons have less complications and better long-term outcomes. Of note, volume is not the whole picture. We need to also consider measurements of surgery and hospital quality and surgeon skill in addition to volume, as Dr. Shawn Menefee insightfully commented.

Dr. Beri Ridgeway gave the Mark D. Walters Lecture about surgeons in the c-suite and the importance of having a seat at the leadership table as surgeons and medical providers. In her words: “If we aren’t at the table, then we are on the menu.” Overworked and underpaid, burned out doctors feel powerless because they are managed by leaders with a business and not a medical background, and we need to have physicians in leadership who understand how medicine is practiced and to ensure equitable care

Dr. Kelly Wright gave a talk on the environmental impact of gynecologic care—from OR to clinic. She gave examples of how metal, reusable speculums become more cost-effective and produce less waste after only 2-3 uses and how there is no evidence that bouffants reduce surgical site infections (and a reusable scrub cap could work just as well without creating waste). Finally, Dr. Ebony Carter gave an impassioned talk on the need for equity in publication and grant funding in our field. She shared about her initiative through the Green Journal (Obstetrics and Gynecology) to create an issue focused on furthering equity and dispelling racism in medical research.

Later in the afternoon, I attended the Fellows’ Pelvic Research Network (FPRN) meeting, which includes AUGS-SGS (urogynecology fellows) and FMIGS-SGS (fellows of all other gynecologic subspecialities, including minimally invasive gynecologic surgery, family planning, reproductive endocrinology and infertility, and pediatric and adolescent gynecology). Dr. John Gebhart gave an excellent lecture with some impressive photos and videos on how to manage mesh exposure and erosion.

Afterwards, updates were given on the current FPRN projects, and 4 new projects were proposed and underwent audience feedback for improvement. It was exciting to see the multicenter collaborations fostered through the FPRN, and I look forward to seeing which projects will get funded for this upcoming year!

The evening ended with the President's Award Ceremony led by Dr. Cheryl Iglesia, the 49th SGS President, as well as the President's Reception. I also wantd to highlight the winner of the Distinguished Surgeon Award: Dr. Dee Fenner. The remaining awardees are listed on the SGS website (https://sgsonline.org).

Last night around midnight, bleary-eyed from the long flight from Pittsburgh, I walked out into the dimly lit, mild air of Tucson, Arizona. The Saguaro cacti that lined the entrance to the airport stood tall and tree-like, with welcoming green arms. It was as if they too knew that the next 4 days would be filled with the building of new relationships and the strengthening of old ones, as well as with education, innovation, and the sharing of research. That spirit of collegiality, approachability, and connection in an intimate and vibrant meeting is what the Society of Gynecologic Surgeons (SGS) meeting has been known for and why it draws people to come back, year after year.

The first day of the conference was fantastic. As a first-time attendant at SGS, I was excited to have the opportunity to meet and rub elbows with mentors and role models from across the country. My day started off with the SGS Fellows and Young Attendings Course, moderated by 3 incredible faculty: Dr. Matthew Barker, Dr. Sadikah Behbehani, and Dr. Traci Ito. Some high-yield topics such as contract negotiation, developing a urogynecology- or MIGS-based practice, billing, academic promotion, and taking advantage of relationships with industry were discussed at length, and the session ended with a roundtable, where the experts had time to answer questions in smaller groups. One of the quotes that will ring true for many fellows about to embark on the job search was from Dr. Amanda Ecker: “Up until now, you were told where to go and what your schedule is. This is the first time you have flexibility and power to decide for yourself.” Therefore, it is important to reflect on what you really desire and/or prioritize in a job, whether it is location, compensation, protected time, or opportunities for advancement.

In the afternoon, I attended a postgraduate course led by Dr. Veronica Lerner and Dr. Mireille Truong called “The Sim Factor: Making an Impact in Surgical Education.” Several other excellent postgraduate courses were available, including “Advanced Endometriosis Surgery and Pelvic Pain Patient-Centered Approach,” “Social Media Workshop- #Gynfluencing: Using Social Media to Find Your Digital Voice,” and “Urologic Surgery for the Gynecologic Surgeon: GU Injury, Ureteral Stents, Complex Fistula and More.” I was grateful for the hands-on and tangible tools that Drs. Lerner and Truong left the group with—including ideas such as Zoom-based virtual coaching for trainees learning fundamentals of laparoscopic surgery types of tasks, table-top simulation for high-stakes scenarios (eg, operative vascular injury), and the importance of grounding educational activity in objectives and evaluation. I even got to make and take home my own myomectomy model. (Fun fact: The myoma is actually a stress ball wrapped in an Ace bandage and then Glad Press n’ Seal! 

The late afternoon transitioned to an opportunity for trainees to interact with senior SGS members and a welcome reception. The indoor and outdoor spaces were filled with laughing and talking as people connected over drinks and snacks. Finally, the evening ended with a session presented by the SGS Equity Council, “What your Patients REALLY Want to Know.” Patty Brisben, of the Patty Brisben Foundation and founder of the company Pure Romance, was interviewed by Dr. Christine Vaccaro. It was heartwarming to hear how Patty took the stories of women suffering from sexual pain and dissatisfaction and chose to make it her life’s mission to improve women’s sexual health.

Wednesday, March 22. Day 4 of SGS.

Day 4, and the final day of the 49th SGS conference started with a sunrise run up and down the hills surrounding the JW Marriott Starr Resort. After breakfast, I entered the Tucson Ballroom to attend the last 2 scientific sessions of the conference.

Highlights from the first session included a look at postoperative outcomes and complication rates between gynecologic surgeons and general surgeons using the National Surgical Quality Improvement Program (NSQIP) database by Dr. Douglas Luchristt, who showed no difference between the 2 surgical specialties (and even better outcomes by gynecologists in certain operative measures), as well as the work of Dr. Christopher Hong who used 2 separate surgical databases (NSQIP and Michigan Surgical Quality Collaborative) to show that rates of vaginal hysterectomy have been decreasing from 2017 to 2020, even amongst patients who are likely good candidates for a vaginal route of hysterectomy. Dr. Jocelyn Fitzgerald presented her unique mixed methods research on how to better design the gynecologic office to improve the patient experience, using 3,000 Twitter responses to a question on this topic. Lastly, Dr. Emily Aldrich shared her work on better understanding the patient perception of same day discharge after major vaginal reconstructive surgery. An interesting finding of Dr. Aldrich’s study was that the most common response to her question about the “worst part of the surgical experience” was going home with a postoperative catheter, which surgeons often consider a small and temporary discomfort. The first session ended with the passing of the gavel from current SGS president Dr. Cheryl Iglesia, to the incoming SGS president Dr. Rosanne Kho, with much applause and excitement for what Dr. Kho will bring to the table in her new role.

The research presented at the final scientific session of the conference did not disappoint. A retrospective study on the influence of body mass index (BMI) on the time to surgical diagnosis of endometriosis by Dr. Melissa Markowitz found that obesity was associated with a delay of over 1 year in surgical diagnosis of endometriosis compared with normal and underweight patients. Dr. David (Ike) Rahn presented additional findings on his randomized, double-blinded, multicenter trial on perioperative use of vaginal estrogen cream in postmenopausal patients with prolapse. He found that 5 weeks of estrogen cream use was not associated with any improvement in urinary incontinence or sexual function.

Dr. Stephanie Glass Clark used the Premier Healthcare Database to show that that there was no difference in postoperative mesh exposure in patients who underwent a total hysterectomy compared with supracervical hysterectomy at the time of sacrocolpopexy. Dr. Kavita Mishra presented results from the FLOWER trial, which found no difference in postoperative outcomes for transgender women undergoing vaginoplasty for gender affirmation who did and did not undergo preoperative pelvic floor physical therapy. Finally, Dr. Carly Crowder shared her video of anatomy for sacral neuromodulation with some excellent cadaveric dissections to exhibit the peri-sacral and gluteal anatomy.

As the conference ended, raindrops pounded the sandy grounds of the resort as I waited in the lobby for my Uber to the airport. Dr. Rosanne Kho happened to walk by and stopped to speak with me and one of my attendings. She smiled as she asked about our experience at the conference and to wish us safe travels. To me, this moment embodies the spirit of mentorship and connection that is so unique to the SGS conference. I feel incredibly lucky to have met some of the physician leaders of our field, who genuinely want to get to know and help the next generation. This year’s meeting was attended by ObGyn generalists and surgeons of all gynecologic subspecialties and certainly met its goal in addressing topics with an “Impact Factor.” I am inspired by all the work that is happening across the country to move the needle and better our field. This was my first SGS experience, but it certainly won’t be the last. I hope you too will consider attending in the future!

Tuesday, March 21. Day 3 of SGS.

It’s Day 3 of the SGS conference! In addition to the academic roundtables, conference attendees had the option of doing early-morning yoga with Dr. Mireille Truong. Yoga sounded nice, but I spent the morning in bed, catching up on sleep. (My own version of wellness!) The scientific sessions of the day started at 7:30 am, and I especially want to highlight the work of Dr. Amy Askew who performed a randomized controlled trial comparing patient removal of urinary catheters placed for postoperative urinary retention to office removal. She found that patient urinary catheter removal was a feasible and safe option with excellent patient satisfaction and a reduction of in-person postoperative office visits. At the end of the session, Dr. Cheryl Iglesia gave her presidential address, where she shared her journey to becoming the physician, educator, researcher, and leader she is today. She emphasized the importance of being a continual learner and to give back by mentoring and educating the next generation. “Learn it, earn it, and return it.”

This was followed by the Te Linde lecture, given by Dr. Pamela Moalli. An exceptional surgeon-scientist, Dr. Moalli shared about her work on the impact of mesh on tissue, as well as alternative biologic options being developed, such as 3D printed membranes, extracellular matrix scaffolds, and living tissue grafts to create new ligamentous supports for the vagina. She discussed novel research using stem cell transplantation to harness the power of regeneration in the urethra or vagina following injury. I think it is safe to say that the entire room was in awe of the work she has done, and what she continues to do to find better therapeutic options for girls and women with pelvic floor disorders. Her talk ended in a standing ovation. Afterwards, all the University of Pittsburgh Medical Center-Magee Womens Hospital trainees, faculty, and several alumni took a picture with Dr. Moalli (fifth from the right in the picture).

Lunch followed, which included a brief walk around the industry exhibition hall. I then returned back to the Tucson Ballroom to listen in on the next scientific session on surgical ergonomics. Organized by Dr. Amy Park who herself suffered from work-related musculoskeletal injuries, the session was composed of an excellent video by Dr. Abby Stork on stretches to prevent and reduce the risk of surgeon-associated musculoskeletal injuries, especially in vaginal surgeons. There was then a panel of 3 experts, Dr. Noor Abu-Alnadi, Dr. Ladin Yurteri-Kaplan, and Dr. Susan Hallbeck (PhD ergonomics expert), moderated by Dr. Amanda Fader and Dr. Kimberly Kho. In particular, Dr. Hallbeck developed a timer app as a reminder for surgeons to stop every 40 minutes to stretch for 1.5 minutes (orstretch.mayoclinic.org). This has been studied and found to reduce musculoskeletal pain after surgery and improve physical performance without increasing total operating time. If you would like to see some of these between- and in-OR stretches yourself, an informative handout can be accessed at mcforms.mayo.edu.

Tuesday afternoon was left open. I joined Dr. Veronica Lerner, Dr. Kelly Wright, and Dr. Louise Perkins King on a 7.5-mile hike into the surrounding desert hills. We marveled at the many Saguaro cacti, some over 100 years old and towering many feet high, as well as the beautiful yellow, purple, and magenta flowers that were scattered among the desert brush. Several rabbits and deer wandered by us during our hike. On one of the trails, the stone skeleton of an old house stood, once a home to the Bowen family who had moved to Arizona for health reasons. I could see why they would want to move here—I felt such a peace looking at the gorgeous view from what was once their doorway.

After a shower and a lot of stretching, I got ready for the evening event, A Taste and Toast with SGS: Under the Arizona Skies. The food and drink were delicious, and I got to spend the evening catching up with a good friend. We watched as conference attendees assigned to different color teams (red, green, blue, and yellow), fought for the hallowed Golden Uterus Trophy in several competitive gynecology-themed games (eg, throwing sacral neuromodulation needle “darts” at balloons and removing small pom poms from a water bottle with a disposable operative hysteroscope). As the evening progressed, the DJ turned up the music and people made their way to the dance floor. The event served as a fundraiser for the SGS Pelvic Anatomy Group and successfully raised $35,000.

Day 2 of the SGS meeting started off with a gentle sunrise over the cacti-covered hills surrounding the JW Marriot Starr Pass Hotel, the venue for the 49th SGS annual scientific meeting. The first official event of the day after some engaging academic round tables was the recognition of the new SGS members. Much celebration was had over the 18 gynecologic surgeons who were inducted.

The second day included the first 3 scientific sessions of the conference. Some highlights include the work of Dr. Shawn Menefee on a randomized trial of sacral colpopexy, transvaginal mesh, and native tissue apical repair for posthysterectomy vault prolapse; a video by Dr. Matthew Fallon on a robotic-assisted laparoscopic approach to repairing a chronic uterine inversion; and the impact of age on regret following hysterectomy by Dr. Nathan King. Dr. Candace Parker-Autry also presented her work on the impact of perineorrhaphy on both female and male sexual function, and Dr. Cassie (Clarissa) Niino spoke elegantly on the “red bag problem” that exists in all of our operating rooms, which increases pollution and cost unnecessarily.

There were also several excellent talks given. Dr. Jason Wright spoke about the importance of surgical volume on gynecologic surgery. In particular, he noted that surgical volume needs to be considered not only at the surgeon level but also at the hospital level. Higher-volume hospitals will provide better care, in the same way that general, high-volume surgeons have less complications and better long-term outcomes. Of note, volume is not the whole picture. We need to also consider measurements of surgery and hospital quality and surgeon skill in addition to volume, as Dr. Shawn Menefee insightfully commented.

Dr. Beri Ridgeway gave the Mark D. Walters Lecture about surgeons in the c-suite and the importance of having a seat at the leadership table as surgeons and medical providers. In her words: “If we aren’t at the table, then we are on the menu.” Overworked and underpaid, burned out doctors feel powerless because they are managed by leaders with a business and not a medical background, and we need to have physicians in leadership who understand how medicine is practiced and to ensure equitable care

Dr. Kelly Wright gave a talk on the environmental impact of gynecologic care—from OR to clinic. She gave examples of how metal, reusable speculums become more cost-effective and produce less waste after only 2-3 uses and how there is no evidence that bouffants reduce surgical site infections (and a reusable scrub cap could work just as well without creating waste). Finally, Dr. Ebony Carter gave an impassioned talk on the need for equity in publication and grant funding in our field. She shared about her initiative through the Green Journal (Obstetrics and Gynecology) to create an issue focused on furthering equity and dispelling racism in medical research.

Later in the afternoon, I attended the Fellows’ Pelvic Research Network (FPRN) meeting, which includes AUGS-SGS (urogynecology fellows) and FMIGS-SGS (fellows of all other gynecologic subspecialities, including minimally invasive gynecologic surgery, family planning, reproductive endocrinology and infertility, and pediatric and adolescent gynecology). Dr. John Gebhart gave an excellent lecture with some impressive photos and videos on how to manage mesh exposure and erosion.

Afterwards, updates were given on the current FPRN projects, and 4 new projects were proposed and underwent audience feedback for improvement. It was exciting to see the multicenter collaborations fostered through the FPRN, and I look forward to seeing which projects will get funded for this upcoming year!

The evening ended with the President's Award Ceremony led by Dr. Cheryl Iglesia, the 49th SGS President, as well as the President's Reception. I also wantd to highlight the winner of the Distinguished Surgeon Award: Dr. Dee Fenner. The remaining awardees are listed on the SGS website (https://sgsonline.org).

Last night around midnight, bleary-eyed from the long flight from Pittsburgh, I walked out into the dimly lit, mild air of Tucson, Arizona. The Saguaro cacti that lined the entrance to the airport stood tall and tree-like, with welcoming green arms. It was as if they too knew that the next 4 days would be filled with the building of new relationships and the strengthening of old ones, as well as with education, innovation, and the sharing of research. That spirit of collegiality, approachability, and connection in an intimate and vibrant meeting is what the Society of Gynecologic Surgeons (SGS) meeting has been known for and why it draws people to come back, year after year.

The first day of the conference was fantastic. As a first-time attendant at SGS, I was excited to have the opportunity to meet and rub elbows with mentors and role models from across the country. My day started off with the SGS Fellows and Young Attendings Course, moderated by 3 incredible faculty: Dr. Matthew Barker, Dr. Sadikah Behbehani, and Dr. Traci Ito. Some high-yield topics such as contract negotiation, developing a urogynecology- or MIGS-based practice, billing, academic promotion, and taking advantage of relationships with industry were discussed at length, and the session ended with a roundtable, where the experts had time to answer questions in smaller groups. One of the quotes that will ring true for many fellows about to embark on the job search was from Dr. Amanda Ecker: “Up until now, you were told where to go and what your schedule is. This is the first time you have flexibility and power to decide for yourself.” Therefore, it is important to reflect on what you really desire and/or prioritize in a job, whether it is location, compensation, protected time, or opportunities for advancement.

In the afternoon, I attended a postgraduate course led by Dr. Veronica Lerner and Dr. Mireille Truong called “The Sim Factor: Making an Impact in Surgical Education.” Several other excellent postgraduate courses were available, including “Advanced Endometriosis Surgery and Pelvic Pain Patient-Centered Approach,” “Social Media Workshop- #Gynfluencing: Using Social Media to Find Your Digital Voice,” and “Urologic Surgery for the Gynecologic Surgeon: GU Injury, Ureteral Stents, Complex Fistula and More.” I was grateful for the hands-on and tangible tools that Drs. Lerner and Truong left the group with—including ideas such as Zoom-based virtual coaching for trainees learning fundamentals of laparoscopic surgery types of tasks, table-top simulation for high-stakes scenarios (eg, operative vascular injury), and the importance of grounding educational activity in objectives and evaluation. I even got to make and take home my own myomectomy model. (Fun fact: The myoma is actually a stress ball wrapped in an Ace bandage and then Glad Press n’ Seal! 

The late afternoon transitioned to an opportunity for trainees to interact with senior SGS members and a welcome reception. The indoor and outdoor spaces were filled with laughing and talking as people connected over drinks and snacks. Finally, the evening ended with a session presented by the SGS Equity Council, “What your Patients REALLY Want to Know.” Patty Brisben, of the Patty Brisben Foundation and founder of the company Pure Romance, was interviewed by Dr. Christine Vaccaro. It was heartwarming to hear how Patty took the stories of women suffering from sexual pain and dissatisfaction and chose to make it her life’s mission to improve women’s sexual health.

Wednesday, March 22. Day 4 of SGS.

Day 4, and the final day of the 49th SGS conference started with a sunrise run up and down the hills surrounding the JW Marriott Starr Resort. After breakfast, I entered the Tucson Ballroom to attend the last 2 scientific sessions of the conference.

Highlights from the first session included a look at postoperative outcomes and complication rates between gynecologic surgeons and general surgeons using the National Surgical Quality Improvement Program (NSQIP) database by Dr. Douglas Luchristt, who showed no difference between the 2 surgical specialties (and even better outcomes by gynecologists in certain operative measures), as well as the work of Dr. Christopher Hong who used 2 separate surgical databases (NSQIP and Michigan Surgical Quality Collaborative) to show that rates of vaginal hysterectomy have been decreasing from 2017 to 2020, even amongst patients who are likely good candidates for a vaginal route of hysterectomy. Dr. Jocelyn Fitzgerald presented her unique mixed methods research on how to better design the gynecologic office to improve the patient experience, using 3,000 Twitter responses to a question on this topic. Lastly, Dr. Emily Aldrich shared her work on better understanding the patient perception of same day discharge after major vaginal reconstructive surgery. An interesting finding of Dr. Aldrich’s study was that the most common response to her question about the “worst part of the surgical experience” was going home with a postoperative catheter, which surgeons often consider a small and temporary discomfort. The first session ended with the passing of the gavel from current SGS president Dr. Cheryl Iglesia, to the incoming SGS president Dr. Rosanne Kho, with much applause and excitement for what Dr. Kho will bring to the table in her new role.

The research presented at the final scientific session of the conference did not disappoint. A retrospective study on the influence of body mass index (BMI) on the time to surgical diagnosis of endometriosis by Dr. Melissa Markowitz found that obesity was associated with a delay of over 1 year in surgical diagnosis of endometriosis compared with normal and underweight patients. Dr. David (Ike) Rahn presented additional findings on his randomized, double-blinded, multicenter trial on perioperative use of vaginal estrogen cream in postmenopausal patients with prolapse. He found that 5 weeks of estrogen cream use was not associated with any improvement in urinary incontinence or sexual function.

Dr. Stephanie Glass Clark used the Premier Healthcare Database to show that that there was no difference in postoperative mesh exposure in patients who underwent a total hysterectomy compared with supracervical hysterectomy at the time of sacrocolpopexy. Dr. Kavita Mishra presented results from the FLOWER trial, which found no difference in postoperative outcomes for transgender women undergoing vaginoplasty for gender affirmation who did and did not undergo preoperative pelvic floor physical therapy. Finally, Dr. Carly Crowder shared her video of anatomy for sacral neuromodulation with some excellent cadaveric dissections to exhibit the peri-sacral and gluteal anatomy.

As the conference ended, raindrops pounded the sandy grounds of the resort as I waited in the lobby for my Uber to the airport. Dr. Rosanne Kho happened to walk by and stopped to speak with me and one of my attendings. She smiled as she asked about our experience at the conference and to wish us safe travels. To me, this moment embodies the spirit of mentorship and connection that is so unique to the SGS conference. I feel incredibly lucky to have met some of the physician leaders of our field, who genuinely want to get to know and help the next generation. This year’s meeting was attended by ObGyn generalists and surgeons of all gynecologic subspecialties and certainly met its goal in addressing topics with an “Impact Factor.” I am inspired by all the work that is happening across the country to move the needle and better our field. This was my first SGS experience, but it certainly won’t be the last. I hope you too will consider attending in the future!

Tuesday, March 21. Day 3 of SGS.

It’s Day 3 of the SGS conference! In addition to the academic roundtables, conference attendees had the option of doing early-morning yoga with Dr. Mireille Truong. Yoga sounded nice, but I spent the morning in bed, catching up on sleep. (My own version of wellness!) The scientific sessions of the day started at 7:30 am, and I especially want to highlight the work of Dr. Amy Askew who performed a randomized controlled trial comparing patient removal of urinary catheters placed for postoperative urinary retention to office removal. She found that patient urinary catheter removal was a feasible and safe option with excellent patient satisfaction and a reduction of in-person postoperative office visits. At the end of the session, Dr. Cheryl Iglesia gave her presidential address, where she shared her journey to becoming the physician, educator, researcher, and leader she is today. She emphasized the importance of being a continual learner and to give back by mentoring and educating the next generation. “Learn it, earn it, and return it.”

This was followed by the Te Linde lecture, given by Dr. Pamela Moalli. An exceptional surgeon-scientist, Dr. Moalli shared about her work on the impact of mesh on tissue, as well as alternative biologic options being developed, such as 3D printed membranes, extracellular matrix scaffolds, and living tissue grafts to create new ligamentous supports for the vagina. She discussed novel research using stem cell transplantation to harness the power of regeneration in the urethra or vagina following injury. I think it is safe to say that the entire room was in awe of the work she has done, and what she continues to do to find better therapeutic options for girls and women with pelvic floor disorders. Her talk ended in a standing ovation. Afterwards, all the University of Pittsburgh Medical Center-Magee Womens Hospital trainees, faculty, and several alumni took a picture with Dr. Moalli (fifth from the right in the picture).

Lunch followed, which included a brief walk around the industry exhibition hall. I then returned back to the Tucson Ballroom to listen in on the next scientific session on surgical ergonomics. Organized by Dr. Amy Park who herself suffered from work-related musculoskeletal injuries, the session was composed of an excellent video by Dr. Abby Stork on stretches to prevent and reduce the risk of surgeon-associated musculoskeletal injuries, especially in vaginal surgeons. There was then a panel of 3 experts, Dr. Noor Abu-Alnadi, Dr. Ladin Yurteri-Kaplan, and Dr. Susan Hallbeck (PhD ergonomics expert), moderated by Dr. Amanda Fader and Dr. Kimberly Kho. In particular, Dr. Hallbeck developed a timer app as a reminder for surgeons to stop every 40 minutes to stretch for 1.5 minutes (orstretch.mayoclinic.org). This has been studied and found to reduce musculoskeletal pain after surgery and improve physical performance without increasing total operating time. If you would like to see some of these between- and in-OR stretches yourself, an informative handout can be accessed at mcforms.mayo.edu.

Tuesday afternoon was left open. I joined Dr. Veronica Lerner, Dr. Kelly Wright, and Dr. Louise Perkins King on a 7.5-mile hike into the surrounding desert hills. We marveled at the many Saguaro cacti, some over 100 years old and towering many feet high, as well as the beautiful yellow, purple, and magenta flowers that were scattered among the desert brush. Several rabbits and deer wandered by us during our hike. On one of the trails, the stone skeleton of an old house stood, once a home to the Bowen family who had moved to Arizona for health reasons. I could see why they would want to move here—I felt such a peace looking at the gorgeous view from what was once their doorway.

After a shower and a lot of stretching, I got ready for the evening event, A Taste and Toast with SGS: Under the Arizona Skies. The food and drink were delicious, and I got to spend the evening catching up with a good friend. We watched as conference attendees assigned to different color teams (red, green, blue, and yellow), fought for the hallowed Golden Uterus Trophy in several competitive gynecology-themed games (eg, throwing sacral neuromodulation needle “darts” at balloons and removing small pom poms from a water bottle with a disposable operative hysteroscope). As the evening progressed, the DJ turned up the music and people made their way to the dance floor. The event served as a fundraiser for the SGS Pelvic Anatomy Group and successfully raised $35,000.

Day 2 of the SGS meeting started off with a gentle sunrise over the cacti-covered hills surrounding the JW Marriot Starr Pass Hotel, the venue for the 49th SGS annual scientific meeting. The first official event of the day after some engaging academic round tables was the recognition of the new SGS members. Much celebration was had over the 18 gynecologic surgeons who were inducted.

The second day included the first 3 scientific sessions of the conference. Some highlights include the work of Dr. Shawn Menefee on a randomized trial of sacral colpopexy, transvaginal mesh, and native tissue apical repair for posthysterectomy vault prolapse; a video by Dr. Matthew Fallon on a robotic-assisted laparoscopic approach to repairing a chronic uterine inversion; and the impact of age on regret following hysterectomy by Dr. Nathan King. Dr. Candace Parker-Autry also presented her work on the impact of perineorrhaphy on both female and male sexual function, and Dr. Cassie (Clarissa) Niino spoke elegantly on the “red bag problem” that exists in all of our operating rooms, which increases pollution and cost unnecessarily.

There were also several excellent talks given. Dr. Jason Wright spoke about the importance of surgical volume on gynecologic surgery. In particular, he noted that surgical volume needs to be considered not only at the surgeon level but also at the hospital level. Higher-volume hospitals will provide better care, in the same way that general, high-volume surgeons have less complications and better long-term outcomes. Of note, volume is not the whole picture. We need to also consider measurements of surgery and hospital quality and surgeon skill in addition to volume, as Dr. Shawn Menefee insightfully commented.

Dr. Beri Ridgeway gave the Mark D. Walters Lecture about surgeons in the c-suite and the importance of having a seat at the leadership table as surgeons and medical providers. In her words: “If we aren’t at the table, then we are on the menu.” Overworked and underpaid, burned out doctors feel powerless because they are managed by leaders with a business and not a medical background, and we need to have physicians in leadership who understand how medicine is practiced and to ensure equitable care

Dr. Kelly Wright gave a talk on the environmental impact of gynecologic care—from OR to clinic. She gave examples of how metal, reusable speculums become more cost-effective and produce less waste after only 2-3 uses and how there is no evidence that bouffants reduce surgical site infections (and a reusable scrub cap could work just as well without creating waste). Finally, Dr. Ebony Carter gave an impassioned talk on the need for equity in publication and grant funding in our field. She shared about her initiative through the Green Journal (Obstetrics and Gynecology) to create an issue focused on furthering equity and dispelling racism in medical research.

Later in the afternoon, I attended the Fellows’ Pelvic Research Network (FPRN) meeting, which includes AUGS-SGS (urogynecology fellows) and FMIGS-SGS (fellows of all other gynecologic subspecialities, including minimally invasive gynecologic surgery, family planning, reproductive endocrinology and infertility, and pediatric and adolescent gynecology). Dr. John Gebhart gave an excellent lecture with some impressive photos and videos on how to manage mesh exposure and erosion.

Afterwards, updates were given on the current FPRN projects, and 4 new projects were proposed and underwent audience feedback for improvement. It was exciting to see the multicenter collaborations fostered through the FPRN, and I look forward to seeing which projects will get funded for this upcoming year!

The evening ended with the President's Award Ceremony led by Dr. Cheryl Iglesia, the 49th SGS President, as well as the President's Reception. I also wantd to highlight the winner of the Distinguished Surgeon Award: Dr. Dee Fenner. The remaining awardees are listed on the SGS website (https://sgsonline.org).

Last night around midnight, bleary-eyed from the long flight from Pittsburgh, I walked out into the dimly lit, mild air of Tucson, Arizona. The Saguaro cacti that lined the entrance to the airport stood tall and tree-like, with welcoming green arms. It was as if they too knew that the next 4 days would be filled with the building of new relationships and the strengthening of old ones, as well as with education, innovation, and the sharing of research. That spirit of collegiality, approachability, and connection in an intimate and vibrant meeting is what the Society of Gynecologic Surgeons (SGS) meeting has been known for and why it draws people to come back, year after year.

The first day of the conference was fantastic. As a first-time attendant at SGS, I was excited to have the opportunity to meet and rub elbows with mentors and role models from across the country. My day started off with the SGS Fellows and Young Attendings Course, moderated by 3 incredible faculty: Dr. Matthew Barker, Dr. Sadikah Behbehani, and Dr. Traci Ito. Some high-yield topics such as contract negotiation, developing a urogynecology- or MIGS-based practice, billing, academic promotion, and taking advantage of relationships with industry were discussed at length, and the session ended with a roundtable, where the experts had time to answer questions in smaller groups. One of the quotes that will ring true for many fellows about to embark on the job search was from Dr. Amanda Ecker: “Up until now, you were told where to go and what your schedule is. This is the first time you have flexibility and power to decide for yourself.” Therefore, it is important to reflect on what you really desire and/or prioritize in a job, whether it is location, compensation, protected time, or opportunities for advancement.

In the afternoon, I attended a postgraduate course led by Dr. Veronica Lerner and Dr. Mireille Truong called “The Sim Factor: Making an Impact in Surgical Education.” Several other excellent postgraduate courses were available, including “Advanced Endometriosis Surgery and Pelvic Pain Patient-Centered Approach,” “Social Media Workshop- #Gynfluencing: Using Social Media to Find Your Digital Voice,” and “Urologic Surgery for the Gynecologic Surgeon: GU Injury, Ureteral Stents, Complex Fistula and More.” I was grateful for the hands-on and tangible tools that Drs. Lerner and Truong left the group with—including ideas such as Zoom-based virtual coaching for trainees learning fundamentals of laparoscopic surgery types of tasks, table-top simulation for high-stakes scenarios (eg, operative vascular injury), and the importance of grounding educational activity in objectives and evaluation. I even got to make and take home my own myomectomy model. (Fun fact: The myoma is actually a stress ball wrapped in an Ace bandage and then Glad Press n’ Seal! 

The late afternoon transitioned to an opportunity for trainees to interact with senior SGS members and a welcome reception. The indoor and outdoor spaces were filled with laughing and talking as people connected over drinks and snacks. Finally, the evening ended with a session presented by the SGS Equity Council, “What your Patients REALLY Want to Know.” Patty Brisben, of the Patty Brisben Foundation and founder of the company Pure Romance, was interviewed by Dr. Christine Vaccaro. It was heartwarming to hear how Patty took the stories of women suffering from sexual pain and dissatisfaction and chose to make it her life’s mission to improve women’s sexual health.