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Tuesday 23 October 2018
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Stress immunity in surgeons

In surgery, we are all too quick to judge the psychology of our patients; however, understanding our own personality is essential to optimise our own performance. Our surgical decision-making requires the ability to judge the patient’s personality, while simultaneously understanding our own character and temperament, to allow a patient-centred consultation and consent for surgery. 
 

The psychological traits of a surgeon

It is estimated that the prevalence of a psychopathic personality trait within the general population is approximately 1%, however within the world of finance, it rises to 3.5% and is even higher among leaders.1 Surgeons are subjected to a high level of psychiatric morbidity with various factors presented in the literature; long working hours,2,3 working night shifts, divorce,4 medical lawsuits5 or failing to meet continuing medical demands.6 It will therefore not be too surprising to find out that some of the traits associated with a psychopathic personality, such as preternatural calmness under pressure, and an apparent indifference to human suffering when making life or death decisions, are perhaps selected out in those who rise to the top of our profession. 
 
There are traits of a subclinical psychopathy that may benefit the surgical field. These positive personality traits include good relationships with others, social desirability and honesty. Subclinical psychopathy also includes less desirable Machiavellian tendencies that may represent a rejection of an absolute moral standard rather than simply amorality. On reflection, do surgeons more often resist the status quo if it is against their beliefs of best care for their patient? Personality traits do change throughout our lifetimes and careers. A cross-sectional study of 253 trainee and consultant surgeons completed a personality scoring questionnaire showing that with increased seniority, aggression, extraversion and achievement also increased.7
 

Stress immunity

It is known that stress immunity is one of the key personality traits seen in surgeons.7 This is not the first time that doctors have been psychiatrically assessed and found to have had increased psychiatric tendencies compared with the general population. An Australian study using a General Health Questionnaire (GHQ) found that doctors had a psychiatric morbidity in 28% of cases versus 19.5% in the general population.5,8 This study highlights that stress immunity is an over-represented personality trait found among doctors, with higher PPI-SF scores found in surgeons, paediatricians and those working in teaching hospitals.9
 
Surgeons with a high degree of stress immunity may be beneficial, or even essential, to objective care, often making difficult but necessary decisions. This trait may be important in selecting individuals for subspecialty training within the surgical profession, or in providing extra support and training for those who are required to provide optimal care in difficult situations. Such situations may arise during surgery or looking after a critically unwell patient, especially in paediatrics when there are the added emotions of the family and a young patient.
 

Burnout in surgeons

Surgeons have a high prevalence of mental health disorders. They have an increased risk of addiction, depression and suicide. Studies show that surgeons early in their training are at high risk due to high demands, long working hours and low job autonomy. A recent analysis of UK junior surgical trainees showed that only 5% of their time is spent in theatre. The General Medical Council (GMC) national training survey 2014 reported the lowest level of satisfaction found in surgical trainees, with the literature reporting a 1 in 5 dropout rate. 
 
In addition, burnout symptoms among surgeons are a pervasive health care problem characterised by a loss of emotional and physical energy, decreased job performance, and depersonalisation. A comparative cross-sectional study evaluated burnout among surgeons and found 80% of surgeons agreed they should be monitored for signs of burnout. Only 8% sought professional help and 15% used prescription medication or alcohol to combat signs and symptoms of burnout.10
 

Dealing with stress and avoiding burnout

In Germany, a randomised controlled trial introducing stress management training to junior surgeons, showed a statistically significant improvement in perceived stress, resiliency, self-efficacy, and optimism in the intervention group compared with those in the control group.11 The introduction of such interventions enhance the surgeon mindfulness, perceived stress and mood disturbance. This in turn can make the surgeon more resilient, improve performance and patient care.
 
Kashdan and Rottenberg popularised the concept of psychological flexibility, which involves the ability to adapt to various situational demands. The fascination of surgery is the balance of life domains against patient values and beliefs. Psychological flexibility is also affected by positive and negative experiences. In such cases, a ratio of three positive experiences is required to offset a negative one. This ratio is important, and may play a role in why surgical procedures may come in and out of fashion. For this reason, consultation with experts and research allows the surgical profession to balance introduction of new techniques against well tried and tested procedures.12 It is important as a profession to nurture the strengths and positive traits of surgeons to allow the profession to flourish and succeed. Stress immunity as a trait and stress management should be more widely evaluated in surgical trainees in preparation for more responsibility and progression through the specialty. 
 
The surgeon can also help manage stress by appropriate planning of surgical procedures. Mental imagery and preparation improves outcomes following surgery.13 Analysis shows that mental imagery and planning with colleagues and materials enabled ‘rehearsing’ of the surgical procedure. This helps to prepare for intra-operative eventualities too and to better handle stressful events. Low levels of intra-operative stress may have a positive effect; however, excessive stress can cause impaired judgment, decision-making and communication. Trainee surgeons are more sensitive to the harmful effects of intra-operative stress than their senior colleagues in general. This is likely to be due to senior surgeons developing coping strategies over time and having experience in dealing with adverse events.14
 
The ability to deal with stress and avoid burnout is closely linked with job satisfaction and organisational commitment. The value of any health care worker is intimately linked with their level of education, working hours and job satisfaction. Health care services need to pay careful attention to such facts, in order to optimise productivity and job satisfaction. It has been shown that perseverance for long-term goals has an inverse relationship with burnout. Age and gender has not been linked with burnout, but a non-significant trend was found in consultant surgeons compared with trainees. It is thus hypothesised that a degree of grit, or perseverance and stress immunity is required to complete and continue within a surgical specialty. This brings into question what are hospitals and the profession doing to nurture and support surgeons?
 

Increased civility at work

Research has demonstrated civility can be increased at work, and in so doing leads to an enduring reduction in burnout. Improving the effectiveness of both the academic content and supervised practice enhances the social dynamics of healthcare teams. Team-based structures provide a support network and continuity to avoid potential pitfalls, and to recover from unavoidable strains. Emotional wellness and job satisfaction can be implemented with policy engagement, within a supportive team-based environment. 
 
The role of emotions both positive (joy) and negative (anger) also play an important factor in stress immunity and burnout. Surgeons are more likely to absorb emotions from their colleagues, emphasising the importance of the team dynamics within the department. Building resilience to stressful events needs to be an integral part of health care practice. Programmes to develop these coping strategies are fundamental to maintain high level of job satisfaction, wellbeing and patient care.
 
Wetzel et al implemented a stress management programme for surgeons focusing on coping strategies, mental rehearsal and relaxation. The intervention group was shown to improve teamwork, coping skills and even lower heart rate during surgical procedures, compared to the control group.15 Healthcare services and hospitals can help improve stress immunity and reduce the risk of burnout by valuing surgeons and employing achievable goal-based practice. Resilience training for all professionals will create an environment akin to herd immunity, yielding greater reductions in surgical burnout.  
 

Conclusions

Further studies need to evaluate the personality traits and the variation in personality scores within the surgical profession and how these influence or impact on the doctor–patient relationship and outcomes of surgery. 
 

References

1 Gudmundsson A Southey G. Leadership and the rise of the corporate psychopath: What can business schools do about the ‘snakes inside? e-JSBRB 2011;2(2):18–27.
2 Bruce CT et al. Factors affecting female or male consultant stress in an Australian teaching hospital. Med J Aus 2003;179(3):174–5.
3 Schattner PL, Coman GJ. The stress of metropolitan general practice. Med J Aust 1998;169(3):133–7.
4 Hayasaka Y et al. Work environment and mental health status assessed by the general health questionnaire in female Japanese doctors. Ind Health 2007;45(6):781–6.
5 Nash L et al. Psychological morbidity in Australian doctors who have and have not experienced a medico-legal matter: cross-sectional survey. Aust N Z J Psychiatry 2007;41(11):917–25.
6 Nash L et al. Factors associated with psychiatric morbidity and hazardous alcohol use in Australian doctors. Med J Aust 2010;193(3):161–6.
7 Kastne RM et al. A comparison of the psychometric properties of the psychopathic personality inventory full-length and short-form versions. Psychol Assess 2012;24(1):261–7.
8 Taylor AW et al. Mental health status of the South Australian population. Aust N Z J Public Health 2000;24(1):29–34.
9 Pegrum J, Pearce O. A stressful job – are surgeons psychopaths? A prospective comparison study of hospital consultants. Bull R Coll Surg 2015;97(8):331–4.
10 O’Kelly F et al. Rates of self-reported ‘burnout’ and causative factors amongst urologists in Ireland and the UK: a comparative cross-sectional study. BJU Int 2016;117(2):363–72.
11 Mache S et al. An evaluation of a multicomponent mental competency and stress management training for entrants in surgery medicine. J Surg Educ 2015;72(6):1102–8.
12 Kashdan TB, Rottenberg J. Psychological flexibility as a fundamental aspect of health. Clin Psychol Rev 2010;30(7):865–78.
13 Ibrahim EF et al. Mental imagery and learning: a qualitative study in orthopaedic trauma surgery. Med Educ 2015;49(9):888–900.
14 Wetzel CM et al. The effects of stress on surgical performance. Am J Surg 2006;191(1):5–10.
15 Wetzel CM et al. The effects of stress and coping on surgical performance during simulations. Ann Surg 2010;251(1):171–6.

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