A study has revealed that we may need to take a fresh and more nuanced look at the effects of surgeon stress in the operating room.
The research reveals that moderate physiological stress in surgeons may improve patient outcomes rather than add risk.
The study, published in JAMA Surgery, suggests that stress-induced focus at the beginning of surgery correlates with fewer major surgical complications.
While previous studies have linked stress to impaired dexterity, more prolonged operations and adverse outcomes, this research highlights the dual-edged nature of stress.
The prospective cohort study, conducted across 14 surgical departments in four university hospitals in Lyon, France, analysed data from 793 surgeries performed by 38 attending surgeons.
Dr Jake Awtry, a research fellow at Brigham and Women’s Hospital in Boston, led the team that monitored surgeons’ physiological stress through heart rate variability (HRV) analysis, measuring the balance between sympathetic and parasympathetic nervous activity (known as the sympathovagal balance).
The results revealed that patients had a 37% lower risk of major surgical complications when their surgeon displayed higher stress levels in the first five minutes of surgery.
However, this stress did not significantly affect mortality or extended stays in intensive care.
The study adds a nuanced perspective to the relationship between stress and performance, which has traditionally focused on stress as a detriment to surgical outcomes.
Dr Awtry and his colleagues concluded: ‘Although excessive stress or cognitive workload may harm surgical performance, modest amounts of stress may stimulate better performance in individuals with the requisite experience and coping abilities.’
This phenomenon mirrors findings in sports psychology, where moderate stress enhances performance among elite athletes.
The study normalised HRV data for each surgeon, revealing that increased sympathovagal balance early in surgery – interpreted as a marker of heightened focus or arousal – was linked to improved surgical performance.
Adjusted odds ratios indicated a significant association between early stress and reduced complications, even after accounting for patient comorbidities, surgeon age and professional status.
The median age of surgeons in the study was 46, with 58% being professors or associate professors. These experienced surgeons had heart rates averaging 88 beats per minute, and their HRV ratios reflected their physiological responses during the critical initial phase of operations.
So, what are the implications for surgical practice?
The findings align with behavioural science theories that stress when managed effectively, can enhance performance in high-pressure roles.
An accompanying editorial by Steven Yule, chair of behavioural sciences at the University of Edinburgh, likened surgeons to elite athletes who excel under pressure.
‘These findings challenge the traditional view of stress as harmful in high-demand roles,’ he suggested.
He advocated integrating stress-management techniques from sports psychology, such as pre-operation visualisation or mindfulness exercises, into surgical training.
This approach could optimise performance by harnessing stress as a tool for focus rather than a liability.
His editorial concluded that applying these performance-enhancing techniques from professional sports to operating rooms can unlock unprecedented gains in outcomes and foster a resilient surgical culture.”
Training programmes and hospital systems, the researchers say, might benefit from fostering environments where stress is managed constructively – enough stress to heighten focus but not so much that it impairs decision-making.
