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Abstract
Orthopedic surgeons face significant physical and psychosocial stressors during their training as surgical residents and throughout their career. Aside from occupational hazards intrinsic to the profession, two notable and treatable concerns are musculoskeletal pain and emotional burnout, which have a reported prevalence as high as 97% and 56%, respectively, among orthopedic residents. Management of musculoskeletal pain and burnout is essential for promoting surgeon well being, education, and longevity as well as avoiding medical errors and compromises to patient care. This perspective manuscript describes the occupational challenges faced by orthopedic surgeons and promotes a habitual practice of yoga as an adjunct therapy for managing musculoskeletal pain and emotional burnout, and furthermore, introduces the need to reconsider gendered perceptions surrounding orthopedics and the practice of yoga in a profession largely comprised of men.
Keywords: Burnout, musculoskeletal pain, orthopedic surgery, yoga
How to cite this article: Introduction 
The profession of orthopedic surgery requires a prolonged and arduous period of training. In the United States, trainees complete 4 years of general medical education following their undergraduate studies, followed by a 5-year residency in orthopedic surgery and an additional year for fellowship training and sub-specialization. Even after this intensive 10-year training period is concluded, the demands on a practicing orthopedic surgeon require remarkable physical and psychological stamina. Early mornings and long clinic and operative days are integral aspects of the profession. Common elective procedures, such as joint replacement for osteoarthritis, may last multiple hours and involve a great degree of physical strength while manipulating larger limbs and joints like the hip and knee. Unexpected surgical complications and the urgent management of traumatic orthopedic injuries contribute to this often-overwhelming occupational responsibility. In short, orthopedic surgeons face many physical and psychological stressors day-to-day, and awareness and management of these challenges is essential for fostering surgeon longevity and well-being.
As an orthopedic research fellow, I have spent the past year studying and producing research relevant to the various musculoskeletal pathologies affecting patients. An additional part of my responsibilities includes assisting the attending orthopedic surgeons during operative procedures. As I have spent hundreds of hours with my colleagues in the operating theater, I have become familiar not only with the orthopedic impairments afflicting each patient under the surgical drapes, but also the physical and psychosocial stressors affecting the attending and resident surgeons operating diligently on the other side of the patient– physician divide. The challenges impacting surgeons vary widely and range from musculoskeletal pain in the operating room to emotional burnout and deterioration of interpersonal relationships. Over the same time span, I have spent over 250 h in guided Bikram yoga sessions at a local studio in addition to my individual practice and have experienced firsthand the physical and psychosocial benefits of practicing yoga. Yoga has proven invaluable as a supportive element of my studies and training as a future orthopedic surgeon, and I am writing this manuscript with intent to highlight the benefits of incorporating yoga into the lifestyle of orthopedic surgeons.
Occupational Hazards, Musculoskeletal Pain, and Burnout in Orthopedic Surgeons The occupational hazards affecting orthopedic surgeons are numerous, potentially serious, and well-documented. Many of these hazards are intrinsically related to routine procedures in orthopedic surgery, including cuts and blood-borne pathogen exposure from sharps/needlestick injuries, inhalation of surgical smoke from electrocautery, noise-induced hearing loss from drills, mallets, and saws, and radiation exposure from intraoperative use of fluoroscopy.[1],[2],[3] Over 80% of orthopedic residents reported receiving a sharps injury during their training[4] and half of orthopedic surgeons report long-term noise-induced hearing loss as a result of their profession.[3]
Musculoskeletal pain is one of the most common complaints among practicing surgeons, which unfortunately tends to increase with additional years of practice. Orthopedic surgery requires prolonged standing while operating and physical manipulation of the anesthetized patient, which naturally contributes to fatigue and pain at the end of a work day. In a study of surgical ergonomics and musculoskeletal pain among orthopedic residents, 97% of residents reported musculoskeletal pain after a single day operating.[5] The most commonly reported sites of musculoskeletal pain are the neck, back, feet, and shoulders.[5],[6],[7] Musculoskeletal pain has been documented to lead to impairment of stamina, concentration, sleep, and increased irritability in resident physicians. In a similar study among arthroplasty surgeons, occupational musculoskeletal pain was significantly associated with burnout, decreased perceived happiness, callousness, irritability, sleep disruption, and increased alcohol intake.[6] These markers of decreased well-being are perhaps more acute in surgical residents with longer work hours, but these effects also compound with time contributing significantly to burnout and adverse physical symptoms among older orthopedic surgeons.
Burnout, defined by one author as “a work-related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment,” is common among physicians, with one review estimating the prevalence of burnout as high as 56% among orthopedic surgery residents and 28% among attending surgeons.[8] Burnout is associated with decreased work satisfaction and more severe concerns including increased medical errors, depression, and suicidal ideation.[9] The higher rates of burnout among residents are in part due to the dual stressors of acquiring a foundational knowledge of orthopedic surgery combined with overwhelming work hours. In effort to ameliorate the immense workload assigned to residents and reduce medical errors, the Accreditation Council for Graduate Medical Education reduced the work hours for resident physicians to a maximum of 80 h/week, which has failed to correlate with improved mental and physical health in residents.[10] Unsurprisingly, unmanageable workloads, loss of perceived autonomy, work weeks exceeding 80 h, lack of exercise, financial stress, and inability to attend health maintenance appointments are significantly associated with resident burnout.[9],[11],[12]
While the prevalence of occupational burnout and musculoskeletal pain in orthopedic surgeons paints a concerning picture, on an encouraging note, many of the hazards and risk factors described above are modifiable. As an example, protective factors against surgeon burnout include spending time with a spouse, physical activity, and discussing concerns with family, coworkers, or friends.[13],[14] Musculoskeletal pain among surgeons may be reduced through awareness of compromising procedural position, ergonomic optimization, exercise, stretching, and intraoperative breaks.[5],[6] The benefits of regular exercise to the physical and mental health of orthopedic surgeons are well-documented.[15] Notwithstanding the time constraints on surgeons, especially trainees, habitual exercise is likely an integral part of promoting surgeon longevity and well-being. It is my proposal that the regular practice of yoga is one of the most time-efficient and enjoyable methods of avoiding burnout and musculoskeletal pain among surgeons.
Benefits of Yoga to Practicing Surgeons Yoga originated in India as a comprehensive mental and physical practice and has seen widespread adoption in the Western hemisphere as a holistic approach to health and wellness. While the practice of yoga is multifaceted, core components include physical postures, breathing techniques, and meditation.[16] There is a large body of literature describing the benefits of yoga, including improvements in physical health, strength, and flexibility and reductions in stress, anxiety, and depressive symptoms, as well as better sleep and social relationships.[16],[17],[18] As cited above, neck pain is a common complaint among surgeons due to compromising postures while staring downward into the surgical incision, and degenerative cervical spine disease is a known occupational hazard among senior surgeons. Mohan et al. describe improved pain intensity and mood with yoga intervention among individuals with chronic neck pain, with few adverse events.[19] Similarly, multiple randomized controlled trials and systematic reviews have been conducted with yoga used as a therapeutic intervention in patients with chronic lower back pain. These studies universally report improved back pain and functional capacity from yoga therapy,[20],[21],[22] with one study citing improvements in symptoms of depression and anxiety in addition to treating back pain.[23]
Naturally, the physical and psychological benefits of yoga have prompted the exploration of its utility among health-care professionals. Multiple studies have described improvement in symptoms of burnout, musculoskeletal pain, and psychological well-being among health-care workers, as well as demonstrating the feasibility of habitual yoga practice within a workday.[23],[24],[25],[26],[27],[28] For example, Babbar et al. describe outcomes of a yoga-based initiative among resident physicians and report significantly reduced feelings of depersonalization (a common symptom of burnout), increased feelings of camaraderie and motivation, improved quality and duration of sleep, as well as significant reductions in blood pressure compared to peer nonparticipants.[23],[29] In a randomized trial comparing the benefits of yoga to exercise among nurses with chronic back pain, Patil et al. report improvements in back pain among yoga participants, as well as reduction of stress, anxiety, and depressive symptoms, and improved interpersonal relationships and social well-being compared to the exercise group.[27] Loewenthal et al. encourage the availability of virtually guided yoga as a method of increasing participation and adherence among busy resident physicians.[25]
I primarily practice vinyasa and Bikram yoga, and my personal experience with yoga as a surgeon trainee supports these beneficial findings. I frequently experience fatigue, musculoskeletal aches, and stiffness after a day in the operating room, and notice reductions of these physical symptoms as well as improved posture, stamina, flexibility, sleep quality, and general fitness in direct proportion to the time I spend practicing yoga. On a psychosocial dimension, surgery can be a highly stressful environment, and I notice a calming and motivational effect from my yoga and mindfulness practice, as well as a stronger sense of gratitude, compassion, and interpersonal connection. It is important to mention the time constraints on orthopedic surgeons with demanding schedules that may prohibit the dedicated practice of yoga. Still, a reasonable implementation may include 15–20 min of individual vinyasa yoga prior to coming to the hospital today, or alternatively attending evening group yoga sessions, as many studios hold classes late at night to accommodate participants with busy schedules.
Interestingly, there is limited literature describing the use of yoga as an adjunct therapy among surgeons, and many of the studies cited above reference yoga use in professions traditionally dominated by women, including nurses, obstetricians and gynecologists, and dental hygienists.[23],[26],[27] It is well-known that the most common demographic of yoga participants in the Western hemisphere is white, college educated, and female,[30],[31] leading to the perception of yoga as a more feminine practice and physical activity, which in part may explain its decreased adoption among men.[32] In contrast, orthopedic surgery remains an occupation overwhelmingly dominated by men,[33] with women comprising fewer than 10% of actively practicing orthopedic surgeons, even while gender representation of women has increased dramatically in other physician specialties.[34] Due to this gender disparity and the physical demands of the profession, there is a clear caricature of orthopedic surgeons as tall, muscular, hypermasculine, cis/heterosexual men with interests in weightlifting, sports, and other traditionally masculine domains. On a personal note, I meet most of these stereotypic markers of an orthopedic surgeon in terms of my physical appearance and gender identity, yet I find myself enjoying and benefitting from the practice of group yoga where I do not look like the majority of female practitioners. It is common for men to represent fewer than 10% of participants in the yoga sessions I attend, and this might result in discomfort or negative experiences for male practitioners. Despite this perceived incongruence in gender-specific behaviors, in my personal experience, the benefits of yoga therapy are just as available to men as to women in both individual and group settings. Furthermore, an open-minded approach to a perceived gender incongruent behavior like yoga requires an act of self-compassion, humility, and intentionality – virtues that on their own may represent important cognitive steps in addressing pain and burnout.
The practice of yoga among orthopedic surgeons thus represents an intersection of heteronormative gender behaviors in occupational choice and preferred methods of physical activity and stress management. The physical and psychological benefits of yoga are not sex specific, and promoting the practice of yoga among orthopedic surgeons may require questioning traditional notions of masculinity and femininity. This manuscript is not written with intent to downplay the need to address ongoing stressors and unrealistic occupational burdens that contribute to musculoskeletal pain and emotional burnout among surgeons in the first place – excessive work hours and sleep deprivation are notable examples, leading to harm to both physician and patient alike. Nonetheless, there remains a need to address emotional and physical pain among surgeons, and yoga represents a single effective and implementable therapy that can be further utilized among orthopedic surgeons in the individual or group setting.
Conclusion The physical and psychological demands placed on orthopedic surgeons are very real, and an intentional approach to management of musculoskeletal pain and burnout among surgeons is vital in promoting educational development, occupational longevity, and excellence in patient care. Reassessing perceptions of masculinity and femininity in orthopedic surgery and yoga, respectively, may play a role in yoga adoption among surgeons in a profession traditionally dominated by men. While encouraging the habitual practice of yoga should not detract from an honest reappraisal and restructuring of the unrealistic occupational demands placed on orthopedic surgeons, yoga remains a promising adjunct therapy for management of musculoskeletal pain and burnout in orthopedic surgeons.
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Conflicts of interest
There are no conflicts of interest.
References 
Correspondence Address:
Jeffrey Mark Brown
2004 E Sheridan Rd., Salt Lake City, Utah 84108
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijoy.ijoy_129_22
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