Higher levels of physiological stress among surgeons at the start of operations were associated with fewer major surgical complications, according to a new multicenter study.
In the prospective cohort study, published in JAMA Surgery, investigators included 793 surgical procedures performed by 38 attending surgeons across 7 specialties. They found that increased surgeon stress—as measured by sympathovagal balance—was associated with a 37% reduction in major surgical complications.
"These results are illustrative of the complex relationship between physiological stress and performance, identify a novel association between measurable surgeon human factors and patient outcomes, and may highlight opportunities to improve patient care," wrote Jake Awtry, MD, of Brigham and Women's Hospital, and his colleagues.
The investigators measured surgeons' stress levels using heart rate variability (HRV) data during the first 5 minutes of surgery. They specifically analyzed the low frequency to high frequency (LF:HF) ratio, which quantifies sympathovagal balance—a validated measure of physiological stress.
The study included operations performed across 14 surgical departments within four university hospitals in Lyon, France, between November 2020 and December 2021. The surgical specialties encompassed digestive, orthopedic, gynecologic, urologic, cardiac, thoracic, and endocrine procedures.
Among the patients, 52.0% of them were female, with a median age of 62 years. The median surgeon age was 46 years, and 78.9% of the surgeons were male. The investigators found that higher surgeon stress levels were also associated with trends toward reduced intensive care unit stays and mortality, though these associations were not statistically significant after adjustment for patient and surgeon characteristics.
The findings challenged previous assumptions about surgical stress. "Although excessive stress or cognitive workload may harm surgical performance, modest amounts of stress may stimulate better performance in individuals with requisite levels of experience and coping abilities," the study authors noted.
The study controlled for multiple variables, including surgeon age, professional status, time of incision, and patient risk factors. The investigators normalized stress measurements to account for individual surgeon variations in baseline sympathovagal balance.
Notably, the study focused exclusively on attending surgeons performing predominantly elective procedures. The investigators suggested that their experienced surgeon population may have been "well equipped to cope with increased stress" and that they may have lacked sufficient high-complexity, high-stress cases to detect potentially harmful effects of excessive stress.
The investigators acknowledged several limitations, including questions about the reliability of the LF:HF ratio as a stress measure and the lack of correlation with other concurrent measures of psychological stress. Additionally, the study population's high proportion of male surgeons and restricted geographic area may limit generalizability.
This research represented the first large-scale study to demonstrate a positive association between surgeon stress and patient outcomes, particularly when measured at the start of procedures. The findings suggested that some degree of physiological arousal may be beneficial for surgical performance among experienced surgeons.
The study authors concluded that their findings "suggest that optimizing surgeon stress may offer an avenue to improve surgical performance, with increased stress benefitting patient outcomes for experienced surgeons."
One author reported receiving grants from the European Research Council Executive Agency and the French
Ministry of Health during the conduct of the study (not directly paid to him). No other disclosures
were reported.
