1. The Effects of Stress on Surgical Performance C Wetzel, R Kneebone, M Woloshynowych, D Nestel, K Moorthy, J Kidd, C Vincent, A Darzi Department of Surgical Oncology and Technology

2. Association for Surgical Education (ASE) CESERT grant 2003 Acknowledgements

3. Operative stress – a phased study 1.Interviews with surgeons 2.Investigating stress within high fidelity simulations 3.Developing a training intervention

4. “There is no such thing as stress in surgery” (S16)

6. Background Stress affects cognitive processes Stress as a risk factor for surgical performance Little in the literature Why investigate stress in surgeons? How does stress affect surgical performance? How do experienced surgeons cope?

7. Aim Performance Stress Coping Exploration

8. Methods Data collection –Individual one hour depth interviews –Semi-structured with topic guide –Perceived stressors and coping responses –Audio recording and verbatim transcription Data analysis –Key themes identified by researcher –Negotiation of themes within research team –Response saturation

9. Results 17 surgeons Imperial College London teaching hospitals juniorsseniors 710

10. Results Uncommon to reflect on stress All experienced intra-operative stress Coping strategies developed by each individual Not addressed within surgical training

11. Stressors Emergency cases Surgical complications –Errors; bleeding; unsolved problems Advanced tasks –Complex procedure; high risk patients Equipment problems –Missing; equipment failure; unfamiliar Teamwork problems –Incompetent/inexperienced; language problems; interpersonal Distractions –Phone calls; interruptions; bleeps Personal factors –Tiredness; hunger; illness; personal problems

12. Stress responses Physical “ heart pounding”, “adrenaline rush”, “shaking” Emotional “anxiety”, “anger”, “pressure”, “urgency to act quickly” “You are doing the best for your patient and try to keep a clear mind… but in yourself you feel anxious.” (S4) “If you feel under pressure, you start sweating and sometimes I get a… pounding headache… and I just get… very sort of on guard and… you feel that if anyone says any little thing you will just… might explode” (J5)

13. Impact on surgical performance Cognitive performance –Judgment and decision-making “Well [stress] is unhelpful when it clouds your judgement… Sometimes it gets to a point when you feel you can’t make a decision and … you can’t think objectively and stress with tiredness which often go hand in hand… you can’t make a decision on simple, simple things.” (S3)

14. Impact on surgical performance Behavioural performance –Team communication “If I am stressed I am probably pretty much just interacting with the operation in hand and my interaction with anyone else is completely minimal… I become very quiet.” (J5)

15. Impact stress on surgical performance Cognitive performance –Judgment and decision-making Behavioural performance –Team communication Non-technical surgical skills

16. Differences: junior vs senior surgeons Juniors Low awareness of stress Strategies fragmented Marked effect of stress on performance Seniors High awareness of stress Sophisticated strategies Effective stress reduction

17. Surgical coping strategies 1.Early recognition of risks 2.‘Stop and stand back’ technique 3.Control Oneself Situation “…then I’d probably wait for a few minutes just to let my heart rate return to normal and … get over my initial anxiety … and I would use that time to get properly equipped.” (S11)

18. Surgical coping strategies Control of oneself –Physical relaxation –Distancing techniques –Self-talk “Try to be a little bit ‘third person’.... What would be a sensible person’s recommendation to make this operation better for me?” (S12) “I have to keep thinking to myself: ‘I need to stay calm. It’s a problem… but I know I can deal with it… let’s think logically: What is the next step that I need to do to regain control in this situation? (S7)

19. Surgical coping strategies Control of the situation –Reassessment –Decision-making –Team communication –Leadership –Solving the problem “I make myself more commanding, more assertive, let everybody know that I’m in control and if I speak they need to listen and they need to act …. It becomes then a much more hierarchical structure than a team structure.” (S7) “And I think if you take the decisions and they are apparently the right ones the stress becomes less because you think ‘that’s good’ you know, I’ve got control. (S4)

20. Conclusions Stress management is key element of surgical competence Integration of stress training into surgical education Stress Communication Decision-making Judgement Coping

21. Phase 2: simulations Objective stress measures Self-assessment Observer ratings Stress Training Intervention

22. The end

23. c.wetzel@imperial.ac.uk r.kneebone@imperial.ac.uk