A systematic review of biological changes in surgeons' acute stress levels during surgery

Randomized cross-over trial comparing stress responses amongst undergraduates and surgeons with and without background music during simulated surgery

High stress may diminish a surgeon's performance in the operating room. Music is perceived to reduce stress in this setting, however the psycho-physiological effects of music on intra-operative stress in inexperienced and experienced operators is incompletely understood. The effect of music on the psychological (Six-Item State-Trait Anxiety Inventory [STAI-6] and Surgical Taskload Index [SURG-TLX]) and physiological responses (e.g., heart rate variability) was determined to a simulated surgical task (carotid patch-angioplasty) in 15 medical students and 12 vascular surgeons under stressing conditions in a randomised crossover design. Music did not affect the speed or accuracy of the simulated surgical stress task performance. While the surgical task increased SURG-TLX scores from baseline to control (Δ32 [22-42]; mean difference [95% confidence interval]) and to music (Δ30 [20-40]), and increased STAI-6 scores in both conditions, there was no difference between music and control. The surgical task also increased heart rate (peak Δ5.1 bpm [3.0-7.1] vs. baseline p < 0.0001) and an index of cardiac sympathetic nervous system activity, and reduced an index of parasympathetic nervous system activity, with the latter two exacerbated by music (SNS index: 0.14 [0.004-0.27], p = 0.042; PNS index: - 0.11 [- 0.22 to - 0.008], p = 0.032). The more experienced group performed faster and more accurately than the inexperienced group, but there were no psychological or physiological differences in their responses to music. Despite previous research identifying generally positive surgeon perceptions of music on the intra-operative experience of stress, herein, background music failed to improve surgical task performance or attenuate subjective ratings of task load and anxiety, and physiological arousal.

Objective Assessment of Cognitive Workload in Surgery: A Systematic Review

OBJECTIVE

To systematically review technologies that objectively measure cognitive workload (CWL) in surgery, assessing their psychometric and methodological characteristics.

BACKGROUND

Surgical tasks involving concurrent clinical decision-making and the safe application of technical and non-technical skills require a substantial cognitive demand and resource utilization. Cognitive overload leads to impaired clinical decision-making and performance decline. Assessing CWL could enable interventions to alleviate burden and improve patient safety.

METHODS

Ovid MEDLINE, OVID Embase, the Cochrane Library, and IEEE Xplore databases were searched from inception to August 2023. Full-text, peer-reviewed original studies in a population of surgeons, anesthesiologists or interventional radiologists were considered, with no publication date constraints. Study population, task paradigm, stressor, cognitive load theory (CLT) domain, objective and subjective parameters, statistical analysis, and results were extracted. Studies were assessed for (1) definition of CWL; (2) details of the clinical task paradigm; and (3) objective CWL assessment tool. Assessment tools were evaluated using psychometric and methodological characteristics.

RESULTS

A total of 10,790 studies were identified; 9004 were screened; 269 full studies were assessed for eligibility, of which 67 met inclusion criteria. The most widely used assessment modalities were autonomic (32 eye studies and 24 cardiac). Intrinsic workload (eg, task complexity) and germane workload (effect of training or expertize) were the most prevalent designs investigated. CWL was not defined in 30 of 67 studies (44.8%). Sensitivity was greatest for neurophysiological instruments (100% EEG, 80% fNIRS); and across modalities accuracy increased with multisensor recordings. Specificity was limited to cardiac and ocular metrics, and was found to be suboptimal (50% and 66.67%). Cardiac sensors were the least intrusive, with 54.2% of studies conducted in naturalistic clinical environments (higher ecological validity).

CONCLUSIONS

Physiological metrics provide an accessible, objective assessment of CWL, but dependence on autonomic function negates selectivity and diagnosticity. Neurophysiological measures demonstrate favorable sensitivity, directly measuring brain activation as a correlate of cognitive state. Lacking an objective gold standard at present, we recommend the concurrent use of multimodal objective sensors and subjective tools for cross-validation. A theoretical and technical framework for objective assessment of CWL is required to overcome the heterogeneity of methodological reporting, data processing, and analysis.

Preoperative educational briefings: systematic review and novel evidence-based framework

BACKGROUND

The preoperative educational briefing is a focused discussion encompassing trainee goal setting and operative strategy. How to effectively deliver the educational briefing and the associated benefits to surgical learning and performance remain unclear. The aim of this study was to extract common themes from briefing templates, examine the impact on surgical education and performance metrics, and propose an evidence-based, structured framework for future implementation.

METHODS

The MEDLINE, Embase, PubMed, and Web of Science databases were systematically searched for relevant studies that were published between database inception and 15 May 2024. Eligible studies involved surgical trainees and implemented educational briefing in the operating room environment. Results were thematically analysed, identifying 12 outcome measures, organized within Kirkpatrick's model of learning evaluation.

RESULTS

Some 7174 studies were screened, of which 20 met the inclusion criteria. A total of 17 studies compared pre- and post-educational briefing implementation participant surveys focusing on surgical education and performance metrics. A total of 95 statistically significant results were identified, of which 93 demonstrated improvement after the introduction of educational briefing. Benefit was identified in 7 of 7 studies investigating reaction (for example briefing impact), 11 of 13 studies examining learning (for example intraoperative teaching), 12 of 14 studies investigating behaviour (for example goal setting), and 6 of 9 studies examining surgical results (for example trainee autonomy). Thematic analysis of briefing templates demonstrated four key themes, forming the proposed 'Goals, Autonomy, Preparation, and Strategy' ('GAPS') framework for standardized preoperative educational briefing.

CONCLUSION

The implementation of structured preoperative educational briefing significantly improves surgical education and performance outcomes. The 'Goals, Autonomy, Preparation, and Strategy' framework facilitates a deliberate, evidence-based approach to educational briefing for implementation across surgical specialties and healthcare systems.

The effects of stress on surgical performance: a systematic review

INTRODUCTION

Acute stress, the psychological response to short-term challenging stimuli, is frequently encountered in the high-pressure environment of the operating theatre. Surgeon stress is associated with deterioration in surgical performance, surgical team working and compromised patient safety. Given these concerns, the aim of this review was to understand the impact of acute stress on surgical performance in technical and non-technical domains as well as patient outcomes.

METHODS

A systematic review was conducted following PRISMA guidelines. Electronic databases were searched for studies examining acute stress in medical professionals during real or simulated surgical procedures that reported performance outcomes in technical and non-technical skills. Risk of bias assessment was conducted using appropriate tools for each study design.

RESULTS

Out of 1445 identified studies, 19 met the inclusion criteria. In simulated environments, acute stress consistently led to impairment in both technical and non-technical skills during surgical procedures. Technical skill deterioration included higher procedural error rates, longer task completion times and diminished instrument handling. Non-technical skills, such as teamwork and communication, also were impaired under stress conditions. Real-world studies echoed these findings, demonstrating acute stress resulting in higher error rates and impaired non-technical skills. No studies identified surgeon stress as having a causal relationship with patient outcomes.

CONCLUSION

Acute stress significantly impacts both technical and non-technical skills during surgical procedures, impairing performance in simulated and real-world surgical environments. Despite the growing understanding of the detrimental effects of stress, gaps remain in comprehensively assessing its impact on patient outcomes. Further research is warranted to develop reliable stress measurement methods applicable in surgical settings and explore effective stress management strategies.

Surgeon stress, anxiety, and workload: a descriptive study of participant reported responses to fundamentals of laparoscopic surgery exercises

BACKGROUND

Stress while operating is an important contributor to surgeon health and burnout. Measuring stress is key to improving surgeon and patient outcomes, however biological responses to stress during surgery are variable and difficult to interpret. Participant reported measures of stress have been suggested as an alternative, but the most appropriate measure has not been defined. This study's primary aim was to assess measures of anxiety, stress, and workload before and after surgical simulation and characterize the relationship between these measures.

METHODS

Surgeons completed three laparoscopic exercises from the fundamentals of laparoscopy program (peg transfer, pattern cutting, intracorporeal suturing) in a neutral environment and "stressed" environment (ergonomic, noise, or time pressure). State trait anxiety and self-reported stress on a visual analogue scale were collected prior to simulation and again immediately afterwards. The NASA task load index (TLX) was also administered post-simulation.

RESULTS

Of the 26 participants from gynecological and general surgery specialties, state anxiety increased in 98/148 simulations (62%) with a significant mean increase during simulation (32.9 ± 7.9 vs 39.4 ± 10.2, p < .001). Self-reported stress increased in 107/148 simulations (72%), with a significant increase in mean scores during simulation (38.7 ± 22.5 vs 48.9 ± 23.7, p < .001). NASA-TLX scores immediately after simulation ranged from 40 to 118 (mean 60.5 ± 28.7). Greater anxiety and stress scores were reported in "stressed" simulations (43.6 ± 23.1 vs 54.2 ± 23.3; 68.7 ± 27.0 vs 52.4 ± 28.2 respectively) with a significant interaction effect of the "stressed" environment and type of exercise. Anxiety and stress were moderately positively correlated prior to simulation (r = .40) and strongly positively correlated post-simulation (r = .70), however only stress was strongly correlated to workload (r = .79).

CONCLUSION

Stress and anxiety varied by type of laparoscopic exercise and simulation environment. Correlations between anxiety and stress are stronger post-simulation than prior to simulation. Stress, but not anxiety, is highly correlated with workload.

The effect of music on the operating surgeon: a pilot randomized crossover trial (the MOSART study)

OBJECTIVE

The experience of stress is common among surgeons while working in the operating theatre (OT). Understanding and finding ways to mitigate this stress is important for optimizing surgical quality and maintaining clinician wellbeing. In this pilot study, we tested the feasibility and reported the outcomes of measuring the effect of background music on intra-operative surgeon stress in the clinical environment.

METHODS

The effect of Music on the Operating Surgeon: A pilot Randomized crossover Trial (the MOSART study) was conducted over a 9-month period in a single-centre. Vascular and general surgeons acting as primary operators (POs) performing elective, general anaesthetic operations were included. The intervention was surgeon-selected music, and the control was the absence of music. Outcome measures were feasibility (recruitment rate, practicability, and completeness of data), heart rate variability (HRV) indices, the Six-Item State-Trait Anxiety Inventory (STAI-6), and the Surgical Task-load Index (SURG-TLX).

RESULTS

Five POs performed 74 eligible randomized cases. The protocol was well tolerated, and no cases were abandoned. Data was incomplete in 8% of cases. The overall mean (SD) operative SURG-TLX score was 48 (±22). Mean HR increased and RMSSD decreased significantly from baseline, suggesting reduced parasympathetic activity while operating. The presence of intra-operative music was not found to affect the psychological or physiological outcomes.

CONCLUSIONS

A music interventional study of this nature is feasible in the operating theatre environment, though no difference was found between in the music and non-music conditions. Follow-up research in a simulated environment with intensive physiological monitoring could be considered.