Surgeon Stress: What’s the Solution?

While a small amount of acute stress may actually enhance performance, too much can have devastating consequences both in the O.R. and in your own quality of life. Studies show that burnout rates among surgeons range from 30% to 38%.

Although there’s no standardized, professional protocol to combat surgeon stress, early results suggest that a surgeon-based mental skills program to promote mindfulness in the O.R. may be effective.

How Do Surgeons Deal with Stress in the O.R.?

In light of the lack of formal mental skills training, a study at a tertiary hospital in North Carolina looked into how surgical attendings, residents and fellows find their own ways to deal with surgeon stress—and whether such strategies are sufficient.

In the study, surgeons reported they used the following positive coping strategies:

• • Reassessing the situation
  • Developing a mental game plan for surgery
  • Communicating with their team
  • Stopping to “stand back” cognitively to not lose sight of the bigger picture
  • Physically relaxing: deep breathing, muscle relaxation, listening to music
  • Distancing themselves from the situation if circumstances allow

Surgeons also reported defaulting to negative coping strategies as well, including:

• • Getting quiet
  • Yelling
  • Sweating
  • Pacing

While positive coping mechanisms may offset the negative cognitive and physiological effects of stress (e.g. upset stomach, inability to focus, dry mouth, racing thoughts), the negative coping strategies often increase stress by exacerbating cognitive and physiological arousal.

Ultimately, the study found that  82% of their respondents said that formal stress management training for surgeons is needed in the field.

Two Universities Implement Mental Skills Training

Both the University of California San Francisco and the University of Indiana have seen promising results after implementing mental skills and emotional regulation training programs for surgeons, according to a report from the 2020 Academic Surgical Congress.

University of California San Francisco

UCSF’s Department of Surgery launched an enhanced stress resilience training (ESRT) with the goal of developing three skills:

• • Interoception: moment-to-moment situational awareness of thoughts, emotion and sensations
  • Emotional regulation: developing no reaction to internal and external stimuli
  • Metacognition: conscious awareness of one’s cognitive control processes

The program combined classroom time, videos and mindfulness practice with a goal to integrate mindfulness into daily life. Examples of daily mindfulness included:

• • Using emotion regulation techniques in difficult communication with coworkers
  • Mindful walking during rounds
  • Breathing techniques to dispel stress and reclaim attention in the OR
  • Using metacognitive skills to transition out of work and enjoy personal time more fully

After the program, surgery trainees reportedly had less stress, better memory, signs of neural substrate activation associated with executive cognitive function, better emotional regulation, improved two-handed coordination and better performance on laparoscopic simulator tasks, as compared to the control groups.

Indiana University

Researchers at Indiana University also conducted mental skills training (MST) to reduce surgeon stress and enhance the performance of surgical residents. The training consisted of classroom instruction, workbook, videos, didactics with a trained mental skills coach and simulation training.

After training, participants were asked to perform procedures on a porcine model, under both calm and stressful (interruptions, technical challenges, poor assistance, etc.) conditions. Both the subjects and controls performed similarly comparably under normal conditions, but mental-skills-trained residents performed better under the stressful conditions. Participants also demonstrated higher laparoscopic skill retention two months after training compared with controls.

Components of a Successful Program for Surgeon Stress

The success of both programs show that mental skills training can be effective in combatting surgeon stress. According to report from the 2020 Academic Surgical Congress report, effective programs generally share the following common characteristics:

• • Using cognitive training to identify stress and address it through learned skills
  • Demonstrable benefits to executive function, suggesting that behavior is the result of central cognitive changes, not one-offs
  • Improved well-being—greater self-confidence intraoperatively, less vulnerability to burnout, and/or a stronger sense of having better life balance

The authors note that coursework is only part of an effective program. It’s essential to also assimilate the knowledge and incorporate it into everyday life until it becomes a muscle memory. Once that’s done, they attest that participants brains will then automatically employ needed techniques during stressful situations to effectively cope and focus on the task at hand.

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