Surgeon, surgery and stress – Dr Ramesh Singh Bhandari

Surgery is considered as one of the very rewarding disciplines providing good amount of personal and professional job satisfaction. Unfortunately, it is also considered as one of the most stressful professions. Both during the period of surgical training as well as clinical practice, people are prone to developing burnout due to excessive stress. Predisposing factors could be multiple. Multiple studies published overseas have demonstrated that the burnout rate among the surgical trainees and practicing surgeons is very high in comparison to other specialties.

Why surgeons are prone to stress?

In surgical specialties, the job demands extreme amount of hard work, both mentally and physically. Besides this, the working hours are extra-long and just not limited to fixed schedules, and the on-call duties are extremely tiring and long. Most of the times the surgeons are dealing with life-and-death situations and one small error either in judgment or skill can prove fatal. At some busy centers the surgeons are overloaded with patients too. Moreover, the training in surgical specialties is extremely prolonged and even after completing their general and specialty trainings they further need supervised working environment to gain good amount of exposure and develop enough confidence. Each individual surgeon can work independently only after that. These prolonged period of training leads to disbalance in their professional and personal life. Similarly, the compulsion to excel both in academics and surgical practice as well as trying to balance with economical aspects are important factors leading to development of burnout among surgeons. Failure to achieve balance in academic, clinical practice and personal life is again the most important factor for the development of stress among surgeons. Sometimes the pressure on the surgeons by the administration to increase performance also adds up the stress among the surgeons who are already prone to stress because of various predisposing factors. Increasing possibility of dealing with litigations in surgical practice is also one of the strongest factors for surgeons to experience stress and develop burnouts.

What is the prevalence of stress among surgeons?

Apart from some anecdotal reports and expert viewpoints, there has been no published study on this subject matter in Nepal till date. This is one of the very important areas to be researched in Nepal as surgical training and clinical practice in surgical specialties are increasingly becoming very challenging and competitive, and also invite risk of litigations. The number of surgeons in the country has also significantly increased. One US study published in “Surgery” journal in 2001, University of Michigan-Ann Arbor, did a survey on 582 surgeons. Overall, 32% surgeons showed high levels of emotional exhaustion, 13% depersonalization and 4% showed low sense of personal accomplishment. Young surgeons were found to be more vulnerable to suffering stress. Similarly, another Australian study published in ANZ journal of Surgery in 2007 evaluated 126 Surgeons. They found that the surgeons were suffering high level of burnout than the general population. Around 48% of the surgeons surveyed reported high burnout levels. Besides these published reports, there are plenty of other overseas publications supporting the fact that the surgeons are very prone to developing burnout and suffering from stress. It has also been found that the experienced surgeons are more likely to have higher management ability as compared to those younger ones and with fewer years of experience.

What is the effect of stress among surgeons?

Burnout and stress can spill over to personal and professional life. Burnouts can lead to emotional exhaustion, depersonalization and low personal accomplishment. Besides this, stress can be significant contributor to poor health of a surgeon. Anxiety and depression can both be a reason for serious health issues among very stressed and burnt out surgeons. Suffering from broken relationships to drug and alcohol dependence can be a serious issue and at extreme situations they are also prone to suicidal tendencies in lack of timely intervention. Stress and burnout lead to imbalance between personal and professional life which further adds to the suffering of already stressed surgeons and this vicious cycle can continue. Job performance further deteriorates in those surgeons already under stress. This can in fact affect the outcome of the patients being treated. Thus, stress and burnouts have serious consequences which are not just limited to the surgeon suffering from it but also can affect the patient being treated and overall health services of a center.

How can we prevent that?

Despite the high prevalence of stress and burnout among surgeons, there are still ways to reduce it although it can’t be completely avoided. There is no best way to prevent it because it needs to be individualized based on every individual’s working condition, environment, job responsibilities and personalities besides many other factors to be considered. There are plenty of ways described in various published literatures to reduce and prevent stress among surgeons and surgical trainees which could in fact be applied to any other specialty too. The past experience of handling the stressful situation can be adopted even during surgical training periods and in clinical practice too. Identifying priorities both in personal and professional life is a must. One should understand and know one’s limits as to what extent to be devoted to surgery. It may not be very applicable during training but definitely an important issue to be considered while practicing as a professional surgeon. Not everyone can do everything and one should understand one’s limits and potential. Getting inspired from others is definitely rewarding but comparing oneself to others can unnecessarily increase the stress. Trying to balance between clinical, academic and personal life which also includes the financial aspects is a must. Running after one single aspect is definitely going to be non-rewarding and there is possibility of developing stressful situation due to self-understood reasons. Working in a team, sharing responsibilities and asking for help whenever required are of utmost importance in preventing stress and burnout among surgeons. A very supporting family can definitely help dealing with stressful situations. However, not everyone could be lucky enough to have a very understanding family or a colleague. Reading articles, publications and books on stress management can also help significantly.  For those having a concerning level of stress and burnouts participation in formal stress management training programs and also getting timely medical interventions can help. From the administrative perspective, imposing scientifically correct working hours and workloads both on trainees and practicing surgeons can help avoid unnecessary stress and decrease burnouts among these vulnerable population.

In conclusion, surgery is a very rewarding yet stressful discipline due to various reasons and surgeons both as trainees and practicing surgeons are prone to developing burnout and suffering stress. This can have various consequences not just limited to individual but also affecting the whole system. Thus, efforts should be made at the individual level to the level of administrators and stakeholders to prevent and reduce the prevalence of stress and burnout among surgical trainees and practicing surgeons which then will help in creating a safe working environment for service providers as well as increasing the patient safety.

(The author is liver and gastro surgeon and profesor at the TUTH)

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