Okay, so we're going to get started. So the dynamic for the afternoon, like we mentioned in the morning, is we're going to do one presentation. I'm going to have the chance to do this presentation, kind of like summarizing what we spoke in the morning. And then we're going to present the case, or a couple of cases. And then Andy Imada is going to kick off the case discussion. And then what we really want in this part of the session is for you to interact. We want to have a participatory kind of round table for interacting with your experience, the expertise, some cases that you've seen, and many of the cases that we're going to present. So just to summarize the morning session, and like I said, thank you for the people who came back, and welcome for the people who are here for the first time. The main message that we want to project in this session is, you know, how does an ergonomic intervention on ergonomic human factors improve the occupational medicine practice? I mean, understanding the root cause of the problem, that it's causing the musculoskeletal issue at the workplace, it's particularly important, like we spoke extensively in the morning, but not only on the micro level, not only on the actual exposure, but also seeing it as a system, organizationally. And seeing ergonomics and ergonomic interventions as a systematic approach, and not just an individual exposure with a specific exposure, if it's repetitive motion or manual patient handling and all that. So declare no conflict of interest, I always like this slide because, you know, it puts us in context a little bit on how the industrialization has evolved through the years, and we have evolved as a discipline also through the years. When Bernardo Ramacinis first started doing his thesis, you know, with the 1700s, industry 1.0, machinery, water, steam, then we went to 1900s, you know, mass production, assembly lines, so things changed. Now we started having more repetitive motion, strains, overextremity, exposure, then computers came in the 70s, now we have office ergonomics, we have office exposure, typing, the cognitive interaction between the computer system and the user. Then in the 2000s, you know, we have internet, it changed humanity, quite honestly, now with internet and the change and the sharing of information around the world. And now we're experiencing the human cyber physical system, which is basically, I would say the summary of all these years of industrialization, but now everything driven by technology, and the pandemic has put a before and after on us as workers, and also as practitioners, and ergonomists, and occupational physicians, and occupational health specialists in general. Like I said in the morning, when I took the time to present Dr. Richmond's case, because those that don't know, she couldn't make it, but we presented a case this morning, and you know, we spoke about how the industry has changed permanently nowadays with remote work. I mean, right now, remote work has been around for many years, but now remote work is here to stay, and really in every single industry, if you can think of, employers are finding a way for workers to work remotely in different percentages of their time. If you can work remotely 90% of your time, well, you will. But if you're a hands-on type of job person, that does work, hands-on work, then, and you only do 10% of administrative time, well, you will work remotely 10% of your time. So, this remote work is not only here to stay, but it's also being embedded in every industry. And you know, there's also an economic impact for that. Real estate has been decreasing when it comes to office spaces, and thus saving money to companies and all that, but that's another topic. As we know, and we spoke in the morning, I mean, the impact of work-related musculoskeletal diseases is very, very large in the U.S. We're talking about almost 8.5 million non-fatal occupational injuries occur every year with an expenditure of $192 billion a year, this BLS data. In New York State, Dr. Nudu and Fletcher from the New York State Department of Health came up with some interesting numbers of the major clinical diagnosis by occupation in the state, where our clinic is part of the New York State Clinic Network, and we see the musculoskeletal disorders are soaring in every single of these industries. Major work exposures by occupational groups, we can tell that their ergonomic factors are also the largest, we have the largest numbers of exposure, which are, you know, ergonomic. So this tells us the importance of what's happening out there, and as occupational medicine practitioners, you know, we not only need to know these numbers, but also how do we address the issue beyond an individual level and think more preventively, like we mentioned in the morning, as prevention being part of the treatment. I mean, are we doing individual health, or can we address this as a population health level? So these are questions that we're asking, and, you know, we don't have the answers, but we're here to open up on these two sessions, and right now we're going to have some case discussions where we can all interact and make a participatory and open up the discussion to everyone. Ergonomic hazards, among the ergonomic hazards, lifting, manual material lifting and handling, push-pull, very important, Jack mentioned about the Snook and Cerello tables that only a couple of people knew about, and, well, that's what we use them for, and, you know, these are numbers, these are live numbers, these are, they're not very new, they're between 2014 and 2017, but I'm sure the numbers are very similar, at least pre-pandemic, I've got to say. This also summarizes a little bit what we spoke earlier, and this diagram was projected by Andy and by Jack, and I'm not going to repeat it, but I am going to focus a little bit on what each, what are the components that influence what we call ergonomics, which is the, or human factors, which is the interaction of the cognitive factors, physical factors, and organizational factors. What is organizational factors? I mean, Andy and Jack spoke about it extensively, but, you know, we can summarize it on participation, cooperation, social-technical system and environments that interact with the, you know, for example, human-computer interaction, teamwork, perception, memory, reasoning, motor response, human anatomy, physiology, anthropometric, and biomechanics. As you can see, this is broader than being a chirologist, what I call, like Dr. Imada said, I don't sell chairs, so every time I go into a workplace, the first thing that I always, you know, they mention that, oh, here's the guy who's going to come and change my chair, but as you, you know, as you can see in the first session and we're going to have in the second discussion, it's way beyond changing a chair, which, by the way, changing a chair is very important, but, you know, I'll be also very careful on what people call ergonomics, you know, that's a very commercialized term. So we are beyond a chirologist, and we spoke extensively in the morning, and we have to see it as a systematic approach. You know, are we focusing just on the actual exposure, repetitive motion, the biomechanical exposure per se, or are we seeing it as a system, like it was mentioned this morning, that we see it as an environment? So when we have a patient in front of us with some muscular-skeletal disorder or pain, we either ask ourselves first, you know, what do you do for a living, of course, you know, where do you work, what's your industry, what are your tasks, your everyday tasks, but beyond that, what is around you? What are you interacting? Are you happy at work? Do you have a really nasty boss that's harassing you? You know, these are things that sometimes we take for granted, and we as ergonomists actually take really, we take it for granted, and it's part of the systematic approach of doing a workplace treatment and thus having safer workplaces and resulting in a healthier workforce, of course. I really like this slide because it kind of summarizes what we all spoke about, and, you know, we are a system. We as humans, we're also a system, and our muscular-skeletal disorders also function as a system. Sometimes, you know, you go to workplaces and you do all types of ergonomic interventions. You have adapting workplaces to everyone's anthropometric measurements, and you do it, you know, you do it physically as good as you can, but the people are not getting better. So what's happening? Are they stressed? Is there a psychosocial impact? Are they having presentism? What's presentism? People are at work, but they're mentally somewhere else. So is this part of the contribution of human error? Why are people committing so many errors at work, you know, getting injured or having, you know, the actual potential muscular-skeletal issue? We know that high levels of psychosocial risk factors, you know, it translates to work-related stress, and we know that there's a hormonal response in our body, you know, cortisol levels elevate, and that, you know, it's well-published how that influences on the muscular-skeletal system and exacerbates some type, some muscular-skeletal issues and make it worse. Earlier, we spoke about you can't have mental, you cannot be mentally, you say it, Andy. You said it. You said it really beautifully. I said that there are not any physical disease that doesn't have an impact on our minds or there are not any mental issues that do not have an impact on our bodies. There you go. So what does that mean? So, you know, she's really literally talking about this part of this slide. The stress response has a hormonal response, a muscle tension response, which contributes to cumulative tissue damage, and, you know, we all focus on the biomechanical part, fine, but it's a system, you know, everything works as a system, and at the end of the day, if we don't break this system, we're only putting out fires, you know, we're not really improving the root cause of the problem. So you can have a great setup, but if the person is being bombarded by phone calls where they just curse you on an office setting while as a customer service worker, you know, it doesn't matter the setting, you know, there's an external factor that's really contributing to your issues. So you know, we have to see it as a system and we got to ask the right questions and we got to understand what's happening at work physically and environmentally and also the person, how is adapting, how is the workplace adapting to the worker. Respecting our limits, you know, we know anatomy, we know physiology, but we usually, you know, we usually see this as what are people able to not do, what are people, what are the limitations of biomechanically of the workers, but you know, sometimes, you know, we tend to preferably work on what people can do and that way we can really adapt the workplace to the workers. So you know, occupational medicine and ergonomics, they should be related to each other in medical care. We need to know what's happening in the workplace. We have a patient in front of us who is, most of us are anthropometrically different. Where are we working? Are we adapting the workplace to the workers' size, measures, gender, age? All these things matter and adapting to the workplace, to the worker is really what we should do and not adapting the workers to the workplace, it's the other way around. This is a list of the technical committees of the International Ergonomic Association just for you to have a glimpse of how broad it is. So technical committees are, you know, we can call it scientific committees in ICO. The name is not relevant, but it is good for you to understand and obviously you can go into the website and there's tons of information in the IEA website. You can click on all this and ask occupational physicians, these are basically all the things that we as ergonomists can really contribute to the practice and to the well-being of the patients, depending on the industry you work on, depending on where you are located and respecting the practice that each one of us does. And I'll leave my presentation with this question or statement. Is prevention part of the treatment? I think it is and I think it should be. Like we mentioned in the morning, we are all embedded on a curative model. We've got to cure what's wrong, we've got to cure what's wrong. But I want you to leave with the thought that primary prevention is what's really going to make a difference. We're not here to talk about the opioid crisis, but it is kind of related. You know, people with chronic pain due to work-related injuries and diseases, and we have all this, I don't want to get political, but we have all this money going around for opioid research, basically focusing on creating more drugs to prevent death. And there's very little done, there's very little research being done on primary prevention. You know, why are people getting hooked? So you know, these are questions that we ask ourselves. And when we as ergonomists see it, see it that way. So it's a system approach, definitely understanding the biomechanical exposure, determining the root cause of the problem. Why are people getting injured? How can we prevent it? You do great medical care, but like Johanna said on her presentation, are we sending them back to the same place they got injured from the beginning? From the get-go? Well, because you know, it's, I remember one of my good teachers when I went to, when I did my occupational medicine residency down in Venezuela, he told me, you have to put on your steel tip boots and you have to go and walk and see what's going on out there. And you know, that's really one of the reasons why I fell in love with ergonomics and I dedicated my life to ergo. Primary prevention, very important. Safe return to work and follow-up, of course. Okay. This was just a little summary of what we spoke in the morning. I was supposed to do this presentation in the morning, but you know, we ran out of time because of the great discussion. So this is my presentation for now. Now we're going to move on to the case discussion. Okay. So the idea here is that we are going to sit here, look at you and you're going to look at us and we're going to interact. Right? Right? Some of us are more extroverted or introverted than others, but that's what's going to happen. I do want to welcome Dr. Igor Belov to this session. Great friend and colleague. He's an ergonomist as well. He works in Venezuela. He represents the Latin America Occupational Health Association, as well as PAHO, right? Okay. So, Andy? So we want to kick it off with the case. Okay. Can you put the next presentation? Oh, there it is. There you go. Who had an urgent matter that couldn't be here for the first session? I just... Okay. I hate to say who didn't show up, right? But who had surgery that they had to be doing this morning? Anyway. Let me do the kind of Netflix review since you weren't here last week on Downton Abbey. We talked about ergonomics as being this distinct relationship between human activities and context. There's some of us that work in the interface between the human and the activity, some of us that work between the activity and the contextual factors, and some of us who work between the context. But really, macro ergonomics and ergonomics is what Jack said. It's a system. And we have to look at the system. Because even if you have a sore shoulder, the PT who only looks at your shoulder and not asks, what are you doing? How often do you do it? And why do you do it that way? Is misstable. Just describing. So this is the larger context. So I'd like to present two case studies that were in a paper. If you want, I can send you the paper. It was with my colleague, Kevin Langamorales, from the National University in Bogota, Colombia. And we've been working on this model. But we use these two scenarios to illustrate the model. And I'd like to show them to you here for purposes of developing a case. And to show you how we might apply macro ergonomics. And if you forgive me, I'm going to read it because it's important. So I know you can read, but it helps me. Maria was a great worker. She never complained and her production was incredible. She maintained this work attitude through 22 months until she was hired by the company. Based on her hard work and productivity, she got a permanent job at the company. The last two paragraphs is something you may identify with. Two months later, she claimed a disability due to a repetitive strain injury. The occupational health manager was upset considering there was a problem that this woman got through to get into the company. You ever heard that one? And I think the words in Spanish were, I think this one got through. So she could file a complaint, a claim. These are not real pictures, by the way, and her name is not really Maria, but it is a real case. Becoming a permanent employee is very desirable, and people are highly motivated to perform at high levels to gain entry, because it means a stable life. However, this required 22 months of peak performance to gain entry into the organization, where the supervisors are constantly evaluating people's productivity without hiring them. This is a case for Maria, who decided to hide the pain caused by the repetitive activity, overexposure and upper limbs, in order to prove to the company that it was worthwhile to give her a permanent job. She did work through it, but the sensation was that she was trying to get in so she could file a claim. So let's go through that little model that we showed in the first session. So what is the human? This is what we know, right? These are the kinds of facts we would gather, you would gather. It is a female. She's been working for 22 months before she was hired by the company, high performer. She comes from a population that's relatively short, about 1.5 meters, and generally have smaller hands. That's what we know about this case, about the workers. The activity, they're cutting flowers, most commonly roses, busiest day of the year is Valentine's and Mother's Day. They know our holidays really well. They work eight hours, from 6 to 2 in the afternoon. The production rate is cutting between 250 and 400 flowers an hour. The pruners are a typical industry standard. It's nothing unusual about it, but it's really well suited for larger hands. The temperature ranges from 8 degrees to 22 degrees Celsius. That's what this woman is doing. So we have hypotheses already, don't we? Well, what caused this injury? She falls into the categories, right? She's a woman, repetitive strain injuries, I mean, highly repetitive work, short work cycles. But the context is, for 11 months, she worked competing for them to choose the fastest workers to go into an agency. So the next 11 months, she was a temp in this agency, and they were selecting the fastest workers. And so if we look at the last two months, she did file a complaint after only working there for two months. So the occupational health officer, from his or her perspective, had a point. This person was trying to get in. As soon as they get in, they file a complaint. From that person's perspective, it makes perfect sense. From the woman's perspective, having a permanent job with a company is enormous benefits, and she was willing to endure a lot. So what caused the injury? I can't tell you what caused the injury, but unless you step back and look at beyond the things we know about that model, I showed you the National Academy of Sciences model that says biological loading, human reaction, and outcomes, and say, what else was going on? And they said, you know what, the temperature's wrong. You know, the temperature is not ideal, but you don't put roses in nice, comfortable environments for us, right? And you don't tell people, you know what, February 14th, 15th doesn't really matter. What's in a day? Some of us know the answer to that. It's a very big deal. We will get that shipped to the customer by February 14th, and Mother's Day moves, and we don't know why it moves, but here's the date this year. So these are contextual issues. So this is an example of how, unless you look at the system, you cannot actually determine the cause of the problem, and the problem you name is the problem you will solve. If you describe the wrong problem to yourself, you will come up with the absolute right solution to the wrong problem. What caused this injury? Stress. Yeah. Could be, right? Well, we don't know, but it's likely. Absolutely. Is it the company's fault that there are economic conditions that cause people to want a permanent job and not to have permanent jobs? No. It's not the company's fault. We didn't say it was their fault. But they can choose, and it creates stress. Does that stress show up in any EMG or x-ray? Nope. Nope. Do you blame her for wanting to have a stable life for her and her family? Of course not. Could it have been any of those other factors, 250 to 400 flowers an hour? Maybe. Maybe. I mean, I'm willing to entertain this possibility, right? So if you did, as Akron said, put on your steel-toed shoes, you would see that, too. You would go at six in the morning and go, you know what? It's pretty cold in here. And in the afternoon, you'd say, it's pretty warm. The contact stress with the cold, smaller hands. Yeah. When we're reviewing this case, when I look at this case, we're reviewing the human with all the contextual factors, but we also have to take in the fact the activity and the context would be probably different and switched pre-11 months and post-11 months. You see, when she's working as a contract employee, the company has no commitment, no investment per se in the employee. They may be looking at productivity as the number one factor. But once, post-11 months, they're permanent, that she may be enrolled in ergonomics programs. The productivity would be different. I think in the context of all of this, having an occupational health physician engage with the company, create policies with that pre-11 month, post-11 month, would be one solution in which they can, you know, remedy, if prevent, future situations like this. Mm-hmm. Mm-hmm. Okay. Good point. Okay. Other comments about this case? I think we are looking at more information. Yeah. For example, how many days did she work? What else did she do throughout the day? Are you using calculations? We're talking about 400 flowers per hour. So that's a rate of six per minute. So an estimate of one every 10 seconds. If you are starting to look at it, we need to understand how's the position, how often did she do it? Is she doing it per rate? Or is she holding on like, yeah, I'm going to take 20 minutes to talk with the coworkers and 40 minutes to do the production of the flowers? Do we have any pre-existing MSDs? We do need some context because once the numbers are out, they seem impressive. But you have to understand how she's doing it and if she has the correct tools, the correct positions, how's the environment? Is she feeling under pressure or everything? We're missing details. That's a really good point. How do you get that information? Unfortunately, I work for economics too. So I always look at what they're expecting, how are they coming to work? Is she doing okay? Is she stressed? Because sometimes you don't actually understand what she's doing unless you're doing it with her. Yeah. And Zachary said, put on your steel-toed shoes and get out there. Because if we do it only from a manila folder, this is what you end up with. You just look at what's written down and you say, okay. There's a question over here. The gentleman by the wall had his hand up first, I think, and then we'll go here. I guess the case is very interesting and it's like my daily work. You just saw this person. Why are they injured? I don't give warranties. I'm curious about some things that you didn't tell us. I guess my question is, it was immediately apparent to the manager what had happened. And we're accepting it as true because that's how you've presented it. My question is, what was her alternative? As she's working as a temporary worker, if she had made a complaint about her symptoms, if she had been forthright about her symptoms at that point, would anything have been done to correct that or would she simply have been replaced by someone just like her? That's an essential question for me because fixing her issues is one part of this, but preventing another person from going through the same experience and giving the same result to the employer is a totally different question. Those are unknowns, for sure. The whole point of it is, these are the cases you deal with and we are working with incomplete information. Some of us have the luxury of just going and saying, oh, let me go to the warehouse or let me go to the hospital. Some places are far away. So where I work, this is common, very, very common, weekly even. The question I have is, why not involve, say, industrial engineers to see if there are any parameters of certain types of individuals, some scope of work, some tools that can prevent these types of problems? In reality, some people shouldn't do certain jobs. They're just not made to do those jobs because they will end in injury. That's just a reality. It could be a placement issue, right? Wrong person, the wrong job. I also want to add something. Andy said that she had small hands, so there's anthropometrics here involved. Well, the population comes from the people. Yeah, correct, and I would be curious to see the tools that they use, how big are they, and if they are adapted to the population. Sometimes tools at work are designed for different populations where they're implemented, and sometimes it's just procurement just to save money, buys, whatever, and they're not really looking at the population that's going to use it. We can talk about specific hand tools, or we can talk about exit cashiers. Let me get the question on this side. So as part of the discussion, I'd be interested to know what's the rest of the population. I assume she's not unique as being the only woman who's 22, going through as an agency worker as well as the full-time workers. So how many additional people have had similar episodes? So during the break, I was talking to Kevin. Kevin, where are you? Yeah. And I said to him, you know, we talked about Jack's systems approach. Whenever I get called and they say we have a neck pain, and I'll go visit the site, and One of my warranties, I sometimes can make a warranty, but I said, I can fix your neck problems in five days. And he says, really? I says, yeah, and how are your shipping problems? He goes, oh, shipping sucks. The customers are complaining. He's like, and how are your mispicks? That's bad, too. And how are your returns? You see, all these problems are related. When you say that you have a musculoskeletal problem, I am going to fix your shipping problem, your mispick problem, your return problem, and your musculoskeletal, because no one puts their wrist in this position for fun. You do this because the posture that the job forces you to be in. And when you're working like this, it hurts, and you're slow, and you get upset, and you pick the wrong item, and you say, you know what? This has got to go. So ship it. Let them return it. And if you fix one problem in the system, I guarantee you, you will fix other problems. So you don't have a safety problem. You have a system problem. And I think those people with shipping problems have other problems. And your job is to be a problem solver. Our job is to solve people's problems. I just want to add to Andy's, and compliment him on the jack systems, but no. The idea around, we see this when we take this sort of holistic systems approach to companies and start implementing it, where we're focusing in on a worker health and safety issue. They all of a sudden, the companies, when we take the systems approach, all come back to us and say, we learned things about our organization we didn't know. And as a result, we are a better, more efficient company. So I just want to add that experience that we've had with working with companies on implementing these systems approaches, which really look at the conditions of work, and what are the root causes to them. And it gets back to the management systems. So I just want to iterate that that's what we've heard from companies, is that they see this benefit. Yes. I studied with Stover Snook and Sorello at Harvard. And I can tell you that you can blame this one for having small hands. But unless you have a less adverse labor situation, the very idea of having someone be a temporary worker for 22 months, this is essentially temp agencies gone wild. And you're never going to help this woman and her coworkers unless there is some way of improving the labor situation for that particular organization. I understand it's in Columbia. They probably don't have OSHA portabilities. There's no adverse repercussions for that company for counting the number of people with repetitive strain disorders. So you can improve the ergonomics as much as you want, but it will not solve this problem. That's a great point. And in fact, this is a case in Columbia. But we see this at home all the time, at least in New York City. It's our everyday job. And we pair with community-based organizations to actually address that specific issue. And because a lot of the workers we see at the health and hospital system, especially at Bellevue, which is the only occupational medicine clinic in the entire health system that does population health, we see the most precarious and vulnerable workers of the city. So we can copy-paste this to New York. I guess the point I'm trying to make is that, yes, it's in Columbia, but we see it here, too. And that's why it was a relevant case, and we wanted to bring it. Bill. Real quick. I understand the conversion from a contract worker to a fully-employed worker. During that transition, even though it looked like she was a good worker on the face value for 22 months, did anyone ask, is there any reason you would have any difficulty doing this job? Do you have any temporary or permanent disability that would prevent you from being able to do this job? And if so, do you need any accommodation? So, I mean, I know it's in Columbia, but still, if they'd asked that question during the conversion, it might have addressed the causation issues. She might not have gotten the job. I understand that. But at least they could have asked the question. I can almost predict the answer. You know, in the interest of time, let me, I know this is a really interesting case, but I don't know very much about it, because it was in Columbia. And let me move to the second case. So the second case is one that I was involved with. I was a consultant for this company for 26 years, and people asked me when I was going to retire. And I said, retire? I don't even work here. So this company was evaluating, this was a trucking company. And whoever made the comment here earlier about trucks is, you know your business. The trucking company was evaluating automatic transmissions on their trucks, truck fleet, to look at the system-wide change and, you know, to see if they could reduce costs and improve performance. It came to a supervisor's attention that one of his drivers was operating automatic transmission, was complaining about pain in her right wrist. He was wondering, how could this be with no forward shifting? He suspected that the pain was related to off-the-job video game playing, and this was just an excuse. So if you look at the last paragraph again, you get it, right? The supervisor knows these people. They have a relationship. I know who you are. I know what kind of person you are. For God's sake, you're driving an automatic transmission, that's what you do with your right hand. Nobody else complains with manual transmissions. What's your problem? After several rides with an ergonomist, the conversation moved to off-hour activities, and the driver admitted that she did, in fact, spend a lot of time playing video games. Aware of the supervisor's suspicion, she said that the video gaming was not the cause of the problem, and neither was the shifting. She confided that when she was young, her father would hit her. She would raise her right arm to protect herself. Repeated trauma probably induced forearm injuries, likely causing ulnar and possibly wrist pain. However, it was too embarrassing to talk about this personal experience at work and risk potential ridicule. It was easier to attribute the cause to something work-related. So what do we know? Experienced truck driver plays video games and complains with pain in the right arm. That's what you learn from the case. She's now working on a truck with an automatic transmission, but less strain on that wrist. The context is she doesn't want to endure potential embarrassment from other drivers about the real source of the pain. Is this story true? To tell you the truth, I don't know. I actually don't know. What about the shifting? I can probably measure that. I can probably measure the stress, the frequency of the shifting. When you're driving in Los Angeles, you never get out of second gear. She's shifting a lot. I can measure that activity. But it's kind of like baseball. You know, it's kind of like people like nothing lies, there's nothing like facts, right? You look at a box score and you say those are the truths. The Dodgers scored five runs. That's a fact, it is a fact. But you know what? It's made up of all subjective pieces of information. Was that a ball or a strike? I said it was a ball. It's a judgment. He didn't tag him. That's a judgment. The ball never, he caught the ball after the guy tagged the bag. That's a judgment call. We are working with, we are always working with subjective information. People say, well, you can't tell if she was lying or not. It's just a subjective, it is subjective. But so is everything else we're working with. And if the potential cause is a subjective one, you would be a fool to not pay attention to it because she could be a complainer. I cannot tell you that she was not. But the story on the surface of it has credibility and I have to look into it. So, you know, as a occupational physician, should you be doing that? And I don't know. I don't know if we have the time, right, to go out there and to do all of these kinds of cases. These are embarrassing situations, especially in this culture, when you get a locker room full of guys, you can imagine the conversations that go on. You don't want to subject yourself to that. Whether it's true or not, I don't know. I can tell you one thing, I would not, like that flower cutter, I would not say it hurt. I would not say that this was because of my father. So anyways, is it true or not? I can't tell you, but I have to step back and I have to look at the whole situation and ask what are the potential causes for this injury and how do we solve this? Any, does this sound familiar to any of you? Before we go to the questions, I want to add that throughout my career, especially when I worked down in Latin America, there was this term that most workers use, especially the ones doing these type of jobs, like the flower cutter, about the normal pain. A lot of these workers think that pain is implicit in the work they do. It's supposed to hurt. Well, you know, and it's always an issue on trying to make them understand that, you know, hurt, pain is not normal. But you have to understand the context, you know. A lot of these workers, they need to go to work in order to, you know, bring food to the table. And we saw that during the pandemic, how all these, how there was, rightly so, a hyper-focus on health workers because it was a biohazard and the coronavirus situation, but then we had thousands or hundreds of thousands of essential workers going out there with nothing on, being exposed to everything. I'm switching from musculoskeletal to the pandemic part, but I'm just making the analogy. And for all we know, all these workers were either going out because they needed to bring food to the table, food to the table, or just because they needed the city to run or the country to run. And then there was a focus on prevention on that population afterwards. So, you know, going back to the musculoskeletal part, you know, a lot of these workers are always under normal pain and that's where we come in and say, hey, listen, you know, let's fix the root cause of the problem. You know, you're gonna have great medical care, but what's causing the pain? Because it's not normal. Thank you, Akron. Can, let me, I'm gonna try and shift the discussion a little bit and make it about you. As my wife says, it's not always about you. Yeah. Let's talk about the context and try and put you into that kind of a situation and see how you can make a difference. I'd like you to think about a problem, a particular case that you've been working on. It could be a difficult case. And I gotta say this, I've never said this before. Pull out your phones or a piece of paper. Because many of us don't carry paper anymore. I want you to write it down. I want you to write it down and describe this case to you. Go ahead, pull out your phones and text it to yourself. What is the problem? Who is the person? What are they doing? What's the context? Maybe what's the cause and what's the outcome? You know the case, right? There's just one that's been bugging you. I'm gonna give, does it make sense? I just want you to write it down. There's no right or wrong answers. I just want you to describe the problem to yourself. I'll give you two minutes and then the baking begins. You guys don't watch that show, right? Is it cake? I'm gonna give you three or four minutes to address the problem. Just give me a second. How many minutes? Okay. All right, I think let's stop just for now. I'd like to use this as an opportunity to assess our own descriptions of the problem because as I said earlier, the problem you name is the problem you will solve. So what you've just done is named the problem. What are some ways that I can include macro ergonomics into my description of the problem? So first of all, the perspective. In your description, is there a single cause or multiple causes to this problem? Because if you have one single cause, you are very sure of yourself. And it could be that there is just one cause to that problem. Are there organizational levels to this problem that you've described to yourself? Have you described, like the flower cutting company, our culpability in creating this injury? Have you described any competing demands that might have created this injury? Like hurry up and do it safely? So evaluate my analysis of the problem from the number of perspectives that I bring to the problem. What is the assumed causality? Is it internal, the person did it? Is it external, that it was happened to him or her? Is it both? Are there motivations in this that I need to look at? Why was the flower cutter doing this work in spite of all her pain? Why was this driver not saying where that pain come from and saying it was work related? What are the motivations that people have? What are the psychological characteristics? You're not a psychologist, I understand, but there are these things like values, needs, attitudes that people have about PPE, wearing face masks. Those are all things that are contextual that surround the problem that if you ignore, you're only looking at a hand in space. You are not looking at a person. What's the social context? What are the interactions? Who is this person talking to? Who does this person care about to solve this and their attitudes? These are the things we look at, like what's the task, pacing, policies, and practices, and culture that go on. So these are contextual factors that I think are important to look at. So when we come up with our definition, our description of the problem, we tend to have singular focuses. And what I'm suggesting is can we have multiple focuses? Can we step back and be open to the possibilities of what may have caused that problem? So one of the things I'd suggest is add one or more of these variables and explore these options. Ask questions about any of these factors. Because remember, the problem exists and we can't solve it. So going back and sort of like getting the worker back to the same job is futile. So anyways, I just wanted to share some of these ideas about how I do it, the kinds of things I think about to get this kind of contextual factors into your analysis of the problem and how you perceive that. All right? I just had a question on the process. How about cost? How about cost, you know, in all of this? You know, the individual, the organization, thinking through this tool, how would you incorporate that in the paradigm? Because that is a key factor if you're gonna have a large amount of them. Absolutely, absolutely. Well, I have an answer, but many of you deal with this, right? Do you have a solution? One of the things I always argue is total cost, total operating expenses. Because when the supervisor says, but the PPE comes out of my budget, the computer-based training takes people off the line on my budget and when I save the injury, I see nothing. What do I get out of it? It's a very legitimate point. So that argument goes to a much higher level and you have to play at that level to understand that it is the total operating costs that you're experiencing, not the fact that we need to get rid of this temp agency and hire directly, because it is gonna cost you more. It probably is gonna cost you more, because you probably have a little higher turnover unless you have a good selection system. But I always argue total costs. And as we were talking about during the break, it's the alternatives to not having this injury. I shared with Kevin this first year when I came out of, was working with this company. I took their lost work days from 1,300 in one year to 87. And nevermind how I did it, but the manager told his bosses, this is Andy and he saved us millions of dollars. And I never actually thought about it in those terms. But when I thought about it, to get a replacement truck driver is $1,000 a day. I save you 1,200 days, it's $1.2 million. That's total operating expense, right? Because the replacement labor cost is like, well, we needed some drivers. Drivers cannot just keep doing double shifts. They have hours that they have to work. I think to me, it's kind of the big picture of, yeah. So that was great. Thank you, Andy. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. So we still have half an hour. We don't have to stay half an hour, but I would like to turn the mic to you. Most of you have been here for both sessions. Yeah, yeah, so I'm turning it. So I wanna start a Q&A, maybe have a discussion on covering what we spoke on both sessions. Dr. Silverman. Yeah, all of these issues, trying to figure out the etiology of a musculoskeletal injury are all very useful things, but there's one step for that truck driver, for example. If you do a good physical exam and you determine it's carpal tunnel versus two queer veins versus radial ulnar etiology or whatever, that's the first step before you try to figure out the ergonomic issues. And I think that I would emphasize the diagnostic workup and the differential diagnosis, whether you need to do an X-ray, whatever you need to do to narrow it down will give you a good start on the ergonomic aspects of it. And I just wanted to bring up that point that I'd start first with making a differential diagnosis, getting it down and trying to find out where the problem is. Yes. That's a great point, yeah. And it actually helps us to also assess what's happening at work and what are the causal factors if there's any biomechanical, what's a big mechanical load and so forth. So yes, it's a great point. I would just say that that truck driver, now that he doesn't have to do the shift, is keeping his hand on the top of the steering wheel and now has carpal tunnel. Yes. Yeah. Yeah. Yeah. More questions. Yeah. Oh, yeah. I just wanted to ask you guys to identify what your metrics are and how you measure those on success of this program. If it's just bottom line dollars saved, I guess that's one thing, but are we also looking at, do we have less of these injuries? I get it, if you work smarter, not harder. You have less injuries, but are there metrics you're using to govern or to look at what you're doing? You know I'm going to give you that mic, Mike, Jack. Actually, I was going to do Andy's trick and say, ask you guys what you used to do. But in all seriousness, I think, anything about any sort of program is how are you evaluating it? You set an objective. What are the measurable outcomes that you're looking at? So depending on, I'm thinking from a program manager aspect of it, not necessarily an occupational physician, but thinking about a program manager who's creating a program inside a company or any sort of manager within a company that's applying these programs. It's like, what's your evaluation plan? And how are you going to, what are your clear objectives? Is it to reduce the number of injuries? So that's, well, that's going to be your outcome. But then as you start developing the components of the program, what are measurable things in those components that you can measure? And this is something that I think when we start thinking about, Andy talked about total cost, and he talked about it more from the motivational aspect. But sometimes when we start thinking about, well, what are we really impacting? And if we really need to have a good systems model of the processes, and what are they impacting as we go along? And what can we measure along that? We had this intervention that strictly was about increasing worker voice as part of the management system of getting data. You know, we say we need data to help drive the change. And so we were like, as part of our study, we're like, well, our objective here is to increase worker voice in the process. So we put out a metric that measured that. So I think it really depends on what your approach is and what you're evaluating. You have to have a conceptual framework of what is that change. Remember that block diagram I showed from Ben Amick around the highly adjustable workstation. You know, there was all these different things. You can measure knowledge. In fact, Michelle Robinson, who was one of the colleagues on that project, that's one of her things. She's come up with great surveys around ergonomic knowledge of workers and how do they know how to use the equipment and how to use it properly. So, you know, if that's what your goal is, measure that. So I'll leave it at that. If there's other comments you want to, yeah. Thank you. In the corporate world, metrics are very important. We have to measure everything. I was speaking with Dr. Morales and he said, did I have to measure everything? So some companies use these self-assessment tool and they can evaluate by colors, green, red, or yellow. And that's one of the metrics they use. They want, for example, they have goals. So they want to be the 100% of the population to be green or another indicator that is being used, days away from work or numbers of cases that are being under investigation. These are some of the lagging metrics that are being used also when it's easier to evaluate with the computers, with some programs. Yeah. I think if we need to choice a principle idea from the two amazing presentation of cases of Dr. Rimera today, is that ergonomics is about human experience too. Okay, it's a very human science and it's basic to protect the people. Not only about musculoskeletal disorders, it's not about only psychosocial risk, it's about culture, it's about people. In the first case about the flower girl, we think a typical case of the marginal returns, decrease in marginal returns, because how is the better level of action in repetitive action for a worker? What is the better for a worker on their property of performance and health? Is the top performance level? For a company, probably is, because a company is looking for more incomes. And for the worker, probably is too, because a worker, a lot of worker in repetitive actions are involved with a variable compensation system, okay? And is looking for more repetitive action, more production to obtain more bonus for productions. So is the maximum level of performance sustainable in terms of health and in terms of productivity, that this is a very important discussion because we are looking in the companies with repetitive actions, the production cost, but production cost, the lower level of production cost. I was working in Korea, in South Korea, with Samsung Corporation and LG Corporation and other electronic consumer corporations, and it seems to be very interesting because we have production bonus in low quote and the high levels of production. You don't need to, if you exceed the higher level, you don't receive the production bonus. How to keep the health of the workers? In the case of the flow worker, this is some of the important ingredients of the equation. If you have a competition system to obtain a position into the company, or you have an incentive in worker compensation at variable, probably after the top performance comes a descendant curve of productivity. This is the love of Cobb Douglas, you know, and if you are adding more repetitive actions, you go to obtain less and less benefits, less and less income. So you get the top of the curve and then decreasing income. So it's very important. That's an interesting approach. Take off the bonus if you actually produce more than a certain point. Any more questions? Hi there. A lot of what you talked about is like a reactive approach to ergonomics, like there has been an injury before changes are made. How do you approach like a more proactive approach and how do you get buy-in from stakeholders? Say if there haven't been any lost days to injury, you know, low productivity, how do you convince people to buy into this? That's a hard question, but I have to say that the ideal scenario for us is when things are being built from scratch, you know, you're building a company, a system or a building or whatever, and then you go hand-in-hand with the process and start putting in place all the preventive programs from the get-go. But unfortunately, most of us just are hired or called or going to workplaces and systems just to fix problems that are already in place. So it is a preventive, it is a preventive, we should have a preventive approach. But I think that just by having a proactive employer, just by having a proactive employer that would reach out to an ergonomics, to have an ergonomic program to be implemented, it's a big step. It's a big step and, you know, we have tried to prove it today. And I'll leave it, I'll stop there. I think Jack and I think everybody else. You got a good problem. Yeah. He's like telling me I'm skinny enough already. Maybe I don't drink enough red wine. Kind of going back to the previous question, I think one of the things that I really think you should measure is forget the lagging indicator. Well, you need to keep the lagging indicators. But for example, there was a company that was doing behavioral-based safety and one of the things we evaluated was how many behavioral observations have you actually done? What kind of audits are you doing on the workplace? And in doing those observations, they come up with the fact that, hey, you know, there's an easier way to do this. And in that process, improves the design of the work. And so you're right, it's really hard to tell someone, you're skinny enough, don't worry. You're eating enough vegetables. But if you can point out ways that they can change and why they should change, I think it's a great opportunity. So I think the leading indicators. And the second point to that question was, I'll tell you a little secret that I found. When someone contracts with me, I always ask them, and how do you get evaluated? The first guy who told me that, I could keep better track of his metrics than he could. And when he went through the company, he took me right with him because I helped him solve his problem. So I think one of the things is solving other problems in addition to the ergonomic problems. Yeah. In fact, following up on Andy's comment about the previous question, I think in the David Michaels article on HBR, he talks about thinking about leading indicators, sort of let go of the lagging indicators and think about leading indicators, which are more the processy and upstream ones. Now, your question, which is, and Andy's question is really good, but I was thinking about it as you said it, the thing that seems to motivate a lot of worker safety and health is catastrophes, right? OSHA was created out of all this. But at some point, a new company is being formed. So how do they start doing it? And what we know is that how to do it, we know how to do it already. The question is, how do we create the motivation to do it? Regulation is one. That's not going to happen in this country anytime soon. So regulations, but there's community or industry base. There's standards, expectations, values, everybody at this meeting is doing that. But there's also organizations, there's business networks, there's insurance companies, there's all these types of things that are pushing, that can be motivators for companies and industry to take on sort of this approach and to do it from the get-go, have it be a corporate value from the get-go and things like that. So those are some of the things that will motivate a company to do it from the get-go. These are complex systems, so you're not going to always get it right. And even when we build products, we don't get it right. We go through trial periods, we learn, we do continuous improvement, and a lot of safety management systems are continuous improvement. In construction, where everything's changing every day, you have to do that kind of approach. But to build it into the culture and how we do things every day, it does require a set of values, both internally and externally, that motivate companies down that road. Anthony, thank you for your question. I would like just to mention that from the international perspective, sometimes it's a matter of money. Unfortunately, poor countries, not industrialized countries, if they're lucky, it's a reactive approach because most of the time, all the problems are even ignored. So occupational medicine has to be seen in different perspective. We're here in an arena that we are able to speak about resources, something that is not the reality in the majority of the countries because the majority of the countries are not industrialized. I want to get to more questions, and I wanted to close that point with worker participation. I think there's an important factor to be considered about the participatory aspect of these programs. A lot of the time, and that tends to be, at the end, motivational because the workers are the ones who know what's happening in the workplace. We tend to do these interventions with a participatory approach, and if it's done well, it actually motivates even the employer because it improves the work environment, improves the engagement, and people feel proud that they're working on a company, that they're inclusive. A few ways that can be done also, and I want to get to more questions, I think. You have one question. I was just going to respond also and share maybe. So one way, I think, at some point at the ground level, a lot of sites, plants can have, for example, local ergonomic committees that implement the program that a company may define, but it includes management, workers, engineers, medical, industrial hygiene, and it allows a platform that can support reactive as well as proactive. And yes, cost is an issue definitely outside the U.S., it's also an issue for a lot of companies in the U.S., but this platform and this type of committee at a plant level allows you to track it. And maybe today I don't have money to fix because it's a big capital expenditure to change a process, but maybe three years from now, suddenly it comes up, you already defined. And then there are a lot of low-lying fruit that, just like you said, the workers know where the problems are. And so a lot of ergonomic issues don't require huge capital investors, but it requires communication from the different business units at a site to say we can do it. I just was going to go back to the original point of getting to the worksite, and if you're too busy to do that, trying to get some eyes there, I mean, the things that actually pop up in the worksite that you wouldn't expect, you know, the woman who's been working for 22 months, was that tool ever replaced? Is it rusted? Is it no longer sharp after all that usage? I had an experience once to go in and work with some puppeteers that all of a sudden were getting hurt. And the workers, the expert on their job, too. I mean, all I did was ask them, and they were like, we got a new set of puppets and we have to rotate them through. Completely different to operate these puppets than the other ones, and that's why we're getting hurt. And we pulled out some force gauges and looked at the force that it took to operate them, and they were right. It was completely different. We set the puppets back, which was an expensive thing. But you know, really get on site if you can, and if you can't, then try to find some eyes that can get on site for you, because what you think the ergonomic situation is based off of the prior job analysis or whatever may have completely changed in the interim. Say I'm a young occupational physician who attended this excellent lecture, and in my workplace in an area that's not a hotbed of occupational medicine activity, I come to the conclusion I really need assistance of an ergonomist. You guys are unavailable. What are the credentials that we should be looking for in selecting someone? Because I imagine there is a lot of, there are a lot of wannabes out there. My athletic trainer used to tell me he was an ergonomist, because he had four hours of coursework. So I sat on the board for, there is an organization that certifies ergonomists in this country. It is called the Board of Certification and Professional Ergonomics, and the designation is CPE. That's the designation I would look for. There are many others, but this is the one that I think has the most rigorous control. It requires testing and updating, much like your board certifications do. It's certified by the organization that certifies organizations, so CPE, short answer. Actually it sounded like a three-fold question, because the question he brought up I just wanted to relay on that, and then I had my question. So with CPE, let's say we're physicians, we want to pair up with an ergonomist. Would that association have a directory where we can connect with an individual? Are there resources or references or manuals that are considered the gold standard in ergonomics that we can refer to when we're creating programs on our own? Great practical question. I think there is a CPE directory of ergonomists under specialties and locations. And is there a book or a reference that you recommend that we consider like a gold standard within your profession that we can use as a reference to work with? A practical manual? For workplace ergonomics, like one. It's a manual, more of it's a manual. So the Human Factors in Ergonomics Society of the United States, which is HFES.org, they have, I believe they have a lot of those resources there in the website, HFES. And also the International Ergonomic Association has also, under the technical committees that I posted on one of my slides, if you click on the technical committees, for example, for musculoskeletal, you will see there a lot of resources that you can read, you can access, you know, ergonomic assessment tools have been validated. You know, there's a lot to be read in there, too. So I would say the HFES and the IEA, you know, just start there. Thank you. And we're always an email away. Thank you. Also. So now the... They have it. So confirm, the HFES does have it. Thank you. No problem. Now the question, which was more piggybacking on what he mentioned earlier, my colleague, about how do you engage with corporations or individuals in a preventative fashion? I could tell you what I did, which I'm sharing with other colleagues. Many organizations are self-insured. And if you really go to the plan sponsors, you can get a string of diagnoses and the costs for those health conditions. When you... If you engage with your supervisors and with your team and you have their support, you can get those figures. And you can... And based on those figures, on the cost per an employee of how much it costs, because remember, that company's paying... They're paying for that, of all that treatment. You could start developing ergonomics programs with the argument saying, I'm saving you $3 million a year for diabetes per this cohort of individuals. And for a secondary prevention program, especially with obesity, I could tell you firsthand, you'll get full support. But the trick is, again, you have to engage with your stakeholders very early on and also make sure it's a very low cost program. And information, education-based ones tend to be success. And that relates to my question to the panel now. Education and providing a post-ergonomic... You know, you have the ergonomic modification in the workforce. Post-education or post-monitoring. Can you comment a little bit about what would be effective or what has been done or what recommendations are in terms of any of these ergonomic interventions that are provided to us today or exercises that have been done? Post, thank you. One of the things I have found very helpful is to keep collecting the data and keeping the data in front of people. You know, so let's say that you have a breakage problem and we fix the problem, but it's not enough because I want continuous improvement on that thing. So keeping that data in front of people and keeping the participation high in those levels. So we say, we decreased the breakage by 25,000 in one month. But the committee met, we've pulled out another 2,000 just by doing this one thing. Really keeps that going because it's not a diet, it's a lifestyle change. You have to look at improvement and process improvements as a continuous process, not about how did we get rid of this one musculoskeletal problem. So the two things, keep the data in front of people and really get people engaged in follow-up activities. You know, part of this continuous cycle is, you know, how do you engage the workers through that process? And you bring up this idea of education. So Andy sparked an idea in my head and that is something that we try to practice with this continuous improvement cycle, especially if you're using participatory things or increasing worker voice, I mentioned that earlier, is to then report back what's going on. And you might have training or education, you know, that's an education in and of itself. You know, when you're telling people, hey, this happened, we learned from it, and now we want to share that information with you so that you know, A, it reinforces their engagement because you're communicating back to them. They feel like, oh, when something happens, we can say something and something will happen out of it. And I think, you know, and sometimes that is a training. We did that in our one project where we learned all these issues were going on and we're like, hey, and even the management says we need to do some education around this just to rewind people. So, you know, this is the processes we're trying to follow and that's what's happening. So I think, you know, it depends, again, on the situation, but it is when, you know, if you think about any sort of, you know, incident, you usually have an investigation and then there's a report and you do some recommendations. And one of the things that we recommend highly is communicating back to everybody what you learned and part of the recommendations may be to do some training as part of a new piece of equipment or a new procedure or a new policy that's implemented so people actually can take advantage of it. You know, I think a big thing that's happening right now where I am is sick leave policy has changed and informing the managers what's allowable and how do they actually encourage it so you don't have the presenteems issue that he talked about earlier. Thank you. Econometrics and occupational health is a big thing around the world. Now, in Europe, we have congresses especially focusing on economics in occupational health, okay, because it is an important part of the budget of the countries go to the protection of the workers' health. So in the most recent study of the OSHA Europe demonstrate that for each euro spent in prevention have savings over two and a half euros. It's one of the more effective business for the companies, okay? So prevention is a very long thing to take two hours to discuss this thing. But with the savings in hours lost of work to sustain human sustainability, that is a big thing now. But in definitive, ergonomics is the most connected discipline of the occupational health between productivity and health is very important, is a central idea. Great. Okay. So, anybody hungry? If there's any more questions, I mean, we want to leave it here. I do want to acknowledge that there's a lot of questions to the folks that are on the chat. We will get to your questions afterwards and thank you for the participation and for being here. We were delighted to be here with you and thank you for your interest in ergonomics. Thank you. Thank you. Thank you.

ergonomic interventions

occupational medicine practice

root cause

musculoskeletal issues

systematic approach

ergonomics

work-related musculoskeletal diseases

prevention

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contextual factors

workplace safety

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