Being "super surgeon" is not realistic in today's health care environment

Every surgeon would like to be "super surgeon": all surgeries go smoothly, every patient outcome exceeds expectations, and there is never a stressful moment. However, not only is this not humanly possible, the proclivity to appear stress-free can make the problem worse. Ignoring stress can lead to surgical errors, poor outcomes, and ultimately, an inability to handle a crisis. Yes, ignoring stress is what most surgeons try to do.

Fourteen of the 15 participants studied by Arora et al. in "Managing intraoperative stress: What do surgeons what from a crisis training program?" reported that the surgical community does find it difficult to acknowledge stress along with its potential impact on performance. "Stress is perceived as a negative, counterproductive attribute that each individual must cope with on his or her own," state the authors.

Physician education typically does not address stress. None of the interviewees recalled addressing the topic in their curriculums or training.

Instead, most surgeons learn on the job, watching senior surgeons or from making their own mistakes. Unfortunately, this method is ineffective, lacking explanation, feedback or enough time. "The first time that a trainee surgeon encounters a given stressful situation may be when he or she is responsible for dealing with it — hardly a situation appropriate either as a learning environment or in providing safe patient care."

IN CRISIS The researchers examined the key stressors that impact operating surgeons, coping strategies, the perceived value of a structured stress-management intervention, and the potential characteristics of such a program. Information was collected from semi-structured interviews. Participants included 15 surgeons from general, cardiothoracic, trauma and orthopedic surgery with a range of experience.

The current paper confirmed previous findings regarding the cause of acute stress and identified key components for a stress-management program. Potential stressors cited by surgeons include equipment problems (the most common stressor), time pressures, distractions, increased workloads and the challenge of learning new technologies. The specific impact in the surgical suite requires more study, but stress has been shown to affect judgment, decision-making and communication. Ironically, one determination was to avoid use of the word "stress," a suggestion that came from the surgeons who felt the negative connotations would turn others away. "They liked the idea of training but felt that 'stress' was very much a psychological issue and was a bit too 'psychobabble.' A better term suggested was 'crisis training'," says Dr. Arora.

FEELING IT The interviewees also agreed about the components of crisis training, listing the opportunity to experience stress during surgery and assess one's own performance, actual training, and post-program assessment. Curriculum content should focus on recognizing stress in oneself and in others, experiencing the impact of stress on performance, providing effective coping strategies, offering feedback and providing opportunities to practice what has been taught in a safe, simulation-based environment. Didactic education on stress would help to legitimize the problem, emphasize its impact on patient safety, and ideally, diminish the perception that acknowledgement indicates weakness.

Cognitive training should address how the physician's ability or inability to deal with stress affects the team. "One stressed consultant can lead to 15 stressed operating staff," said one study participant. This education could include calming and focus techniques.

Technical training targets performance under stressful conditions and may be best approached today with simulation, although the authors acknowledge that additional research is needed. "It's very difficult to actually get those opportunities without compromising patient safety in real theater. Simulation provides the opportunity to experience this, develop coping strategies and learn techniques from senior people," says Dr. Arora.

Simulation can also help to address team training, particularly since team management was a cause of anxiety for the interviewees. "Managing one's own stress is not enough if the surgeon is unable to lead the rest of the team in remaining calm and effective," write the authors. Individual feedback and self-reflection complete the program. In simulated training, this often takes the form of debriefings, which may include video of the trainees' performance compared to that of a seasoned surgeon. This step helps to solidify the learning objectives; post-training performance evaluation can verify they have put them to use.