Most surgeons report being affected by job-related performance anxiety, with anxiety often having a negative effect on well-being, according to a new study of surgeons in the UK.

“Performance anxiety or stage fright is a widely recognized problem in music and sports, and there are many similarities between these arenas and the operating room,” said first author Robert Miller, MRCS, of Surgical Psychology and Performance Group, UK, and the Department of Plastic and Reconstructive Surgery, St George’s Hospital NHS Trust, London, said Medscape Medical News.

“We were aware of this anecdotally in a surgical setting, but for some reason, perhaps professional pride and fear of negative perception, this is rarely discussed openly among surgeons.”

In the cross-sectional study published this month in annals of surgeryMiller and colleagues interviewed surgeons of all specialties working in the UK who had at least 1 year of postgraduate surgical training.

Of a total of 631 responses received, 523 (83%) were included in the analysis. The median age of those who responded was 41.2 years and the mean length of surgical experience was 15.3 years (range, 1 to 52 years). Among them, 62% were men and 52% were consultants/assistants.

All respondents – 100% – said they thought performance anxiety affected surgeons, 87% said they had experienced it themselves, and 65% said they felt performance anxiety had an effect on their surgical performance.

Male and female surgeons who reported experiencing performance anxiety had significantly worse mental wellbeing, as assessed using the Short Warwick Edinburgh Mental Wellbeing Scale (SWEMWBS), compared to those who did not have performance anxiety (P P

Overall, however, male surgeons had significantly better mental well-being than female surgeons (P = 0.003), but both genders had significantly lower mental well-being scores compared to UK population norms (P = 0.0019 men and P = 0.0001 women).

Gender differences are “clearly an important topic, which is likely multifactorial,” Miller said. Medscape Medical News.

“The gender wellness gap requires further research, and qualitative work involving female surgeons is essential.”

Surgical perfectionism was significantly more common among respondents who had performance anxiety compared to those who did not (P

“Although perfectionism may be a beneficial trait in surgery, our results from hierarchical multiple regression analysis also indicate that perfectionism, [as well as] gender and experience, may lead to surgical performance anxiety and help predict those who suffer [the anxiety]“, note the authors.

Playing in the presence of colleagues is a key trigger

By far, the main trigger that was identified as inciting surgeon performance anxiety was the presence – and scrutiny – of colleagues within the parent specialty. This was reported by 151 respondents. Other triggers were having to intervene in very complex or high-risk cases (66 responses) and a lack of experience (30 responses).

Besides planning and preparation, opening up and talking about the anxiety and shedding light on the problem was seen as a top strategy for dealing with the problem, but very few respondents said they openly shared their struggles. Only 9% said they had shared it openly; 27% said they confided in someone and 47% did not answer the question.

“I wish we would talk about it more and share our insecurities,” one respondent lamented. “Most of my colleagues claim they are living gods.”

Only about 45% of respondents reported a specific technique for overcoming their anxiety. In addition to being open about the problem, other techniques included self-care, such as exercise and distraction outside of work to gain perspective, relaxation techniques such as deep or controlled breathing, music , mindfulness and positive self-statements.

About 9% said they had received psychological counseling for performance anxiety, and only 3% said they had used medication for the problem.

Anxiety a positive factor?

Surprisingly, 70% of respondents reported feeling that surgical performance anxiety could have a positive impact on surgical performance, which the authors say is consistent with some theories.

“This can be explained by the traditional bell curve relationship between arousal and performance, which describes a dose-dependent relationship between performance and arousal up to a ‘tipping point’, after which the performance decreases,” the authors explain.

“Increased awareness secondary to anxiety may be beneficial, but at high doses anxiety may negatively affect attentional control and cause somatic symptoms.”

They note that “the challenge would be to reap the benefits of low-level stimulation without incurring possible adverse effects.”

Miller noted that, to determine if selection bias had a role in the results, detailed analysis showed that “our respondents were not biased towards those who had only high levels of trait anxiety.

“We also had a good distribution of consultants versus interns [about half and half]and different specialties, so we think this is likely a representative sample,” he told Medscape.

That being said, the findings underscore the need for increased awareness – and open discussion – of the problem of surgical performance anxiety.

“In other professions, especially the performing arts and sports, performance psychology is becoming an integral part of training and development,” Miller said. “We believe that surgeons should be supported in the same way.

“Surgical performance anxiety is normal for surgeons at all levels and nothing to be ashamed of,” Miller added. “Speak up, acknowledge it and support your colleagues.”

Many keep it to themselves in “The Dominant Culture of Stoicism”

Commenting on the study, Carter C. Lebares, MD, associate professor of surgery and director of the Center for Mindfulness in Surgery, Department of Surgery, University of California, San Francisco, said she was not surprised to see the rates High Performance Anxiety among Surgeons.

“As surgeons, no matter how hard we train or how well we prepare our intellectual understanding or the patient, the disease process and the operation, there may be surprises, unforeseen challenges or days off,” Lebares said.

“And whatever we encounter, we deal with those things directly under the control of others – people who can affect our reputation, our operating privileges and our mental health. So I’m not surprised that this is a widespread and widely recognized.”

Lebares noted that the reluctance to share anxiety is part of a “difficult and recognized conundrum in both medicine and surgery and is a matter of the dominant culture of stoicism.

“We are often called upon to shoulder tremendous weight during the operation (perseverance, self-confidence or sustained focus) and bear the brunt of complications (which we will all eventually have),” she said.

“So we have to be strong and not complain, [but] we also need to be able to put that aside [when appropriate] and ask for help or let others bear the weight for a while, and that’s not [yet] common part of surgical culture.

Lebares added that randomized controlled trials have shown benefits of mindfulness interventions on burnout and anxiety.

“We observed positive effects on mental noise, self-perception, conflict resolution and resilience in surgical residents trained in mindfulness-based cognitive skills,” she said.

“[Residents] report applying these skills in the operating room, in their home life, and in how they approach their training/education. »

The authors did not disclose any relevant financial relationship. Lebares has developed mindfulness-based cognitive skills training for surgeons, but receives no financial compensation for the activities.

Anne Surg. Published April 2022. Summary

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