Shut out stress, stay focused to maximize performance in operating room
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Life is full of stressors, but surgeons cannot afford to let them interfere with their performance.
Surgery requires intense concentration, a calm and focused mind, and therefore the ability to control stress and anxiety.
“We are working with delicate ocular tissue in such a small volume of space, less than 1 mL, a space that is so small that any little deviation can cause an error, a problem or a complication,” Uday Devgan, MD, said.
In addition, there are challenges outside the OR, bad and even good events. But during those intense minutes of surgery, surgeons cannot afford to let these events interfere with their performance.
“If professional athletes perform at a 90% level, you are impressed. But for you, the surgeon, it has to be 100% because even just one out of 100 patients with a complication will upset you. While so many U.S. medical schools have changed from grades to simply pass-fail, that is not reflective of the reality that you will face in the future. Every patient wants a perfect score, 100%, from the surgery that you perform on their eyes. I have never met a patient who asked for merely a passable job,” Devgan said.
Compartmentalize
First, everyone should have a healthy outlet. Exercise in almost any form can act as a stress reliever.
“For me personally, it is weightlifting, and mountain biking. They are great outlets, and it is important for me to get that stress out so that when I am in the operating room, I am fresh and ready,” Devgan said.
Other ways of dealing with stress, such as alcohol and substance abuse, should be avoided. A healthy body, a healthy mind, taking care of oneself and cultivating peace of mind are crucial to perform to the best of one’s abilities, he said.
“Also, spend time with your family and friends, enjoy the great outdoors, pet your dog. All the above help release stress,” he said.
Once in the operating room, all energy and attention should be focused on surgery, and for this, every surgeon should learn how to compartmentalize. Relationships, business, personal issues, memories and projects should go out of focus and be set aside in a separate compartment of the brain.
“All that matters in that moment is my patient, my hands, my surgery. During those 5, 10 or 15 minutes of super-intense concentration, you cannot afford to have your mind on anything other than that surgery because your surgery will change the way your patient is going to see the world at every moment of their life forever,” Devgan said.
Compartmentalization may not be easy. It is a skill one has to learn, but it is not out of reach for anyone.
“You’ll have to work on it. It takes some practice, but you can do it, and the mind is your most powerful weapon. Meditate if you need to. Find your special place, your special way. Do what it takes, but you have the ability to compartmentalize, to achieve that sort of concentration. And once you are in the OR, focused on that very moment, you are no longer stressed, you are no longer nervous, and you can perform your maneuvers calmly and precisely,” Devgan said.
The power of concentration
In a study by Chandra and colleagues, stress levels during uncomplicated cataract surgery were measured in experienced consultants and trainee surgeons by measuring blood pressure, pulse rate, oxygen saturation, blood cortisol levels and urine catecholamines levels (adrenaline, nor-adrenaline and dopamine).
Not surprisingly, the study showed that, although stress levels increased in every surgeon, the difference between trainee surgeons and consultants for different parameters was statistically significant. Interestingly, however, urine nor-adrenaline levels showed a significantly higher increase in consultants.
Nor-adrenaline’s primary role is arousal. It boosts awareness, concentration, responsiveness and reaction speed.
According to the study authors, “This indicates that consultants are more focused, alert and aroused during the intraoperative period whereas urine adrenaline levels showed a higher increase in trainee surgeons which indicates that they are more anxious and afraid during the intraoperative period, which causes the body to release a flood of adrenaline.”
“Many residents ask me how they can improve concentration and often tell me they find it hard to focus when they are stressed out by things going on at home or at school. I tell them they have to learn to compartmentalize, and that they can do it. They will learn this with practice and experience,” Devgan said.
He also tells residents that they must take advantage of their years of training to maximize their learning and hone their surgical skills.
“I tell them they can continue acquiring knowledge for the rest of their life, but they have a very finite time in which to be directly proctored to learn ocular surgery. Once they finish training, they are on their own. There will be no attending surgeon or professor to bail them out,” he said.
Residents often say that the presence of an attending surgeon makes them nervous. This is understandable, but they should learn to approach this kind of anxiety from a different perspective.
“As an attending, by sitting next to you, I can save any case, help with any tricky maneuver and recover from just about any complication. I am also absorbing the vast majority of the liability for the case since the attending surgeon is responsible for everything. You should rest assured that with your attending surgeon seated next to you in the surgery, you have a much wider margin of safety,” Devgan said.
Less stress with more experience
An ongoing study, presented at the American Society of Cataract and Refractive Surgery meeting in Washington by Timothy W. Grosel, MD, included 13 residents and six attendings, comprising 549 surgeries. Researchers used heart rate as a surrogate for stress by attaching a Bluetooth device to the surgeons’ and attendings’ chests during surgery.
Results showed that stress decreased as surgeons gained more experience during residency. It also showed that supervising residents as an attending can be even more stressful, but time and experience again help. Attendings with more than 10 years of experience had significantly lower heart rates compared with attendings with fewer than 5 years of experience.
With his long experience and through practicing compartmentalization, Devgan has learned to keep calm and even control his heart rate during surgery, including in highly stressful situations, such as operating on the family member of a colleague or doing live surgery at a large international meeting.
“In some of these circumstances, I wore a heart tracker during the process, which showed that I did not experience a single episode of tachycardia. My heart rate never went above 80 beats per minute,” he said. “I am not that special — you can learn this, too.”
References:
- Chandra T, et al. Clin Ophthalmol. 2020;doi:10.2147/OPTH.S266501.
- Devgan U. Learning to compartmentalize. https://cataractcoach.com/2021/12/25/1328-learning-to-compartmentalize/.
- Grosel T. Attending stress levels during the steps of cataract surgery. Presented at: American Society of Cataract and Refractive Surgery meeting; April 22-26, 2022; Washington.
For more information:
Uday Devgan, MD, is in private practice at Devgan Eye Surgery and partner at Specialty Surgical Center in Beverly Hills. He can be reached at 11600 Wilshire Blvd. #200, Los Angeles, CA 90025; email: devgan@gmail.com; website: www.CataractCoach.com.
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