How important is it for a surgeon to know about a patient's mind-set? Hardly anyone would think of this as a ‘life-and-death’ issue. Unfortunately, for a plastic surgeon in Madrid, this was exactly the case, when a dissatisfied patient killed him. The situation is not unique. Between 1995 and 2005, five plastic surgeons were killed in the USA by their patients. Although these extreme acts of violence are rare, surgeons nowadays regularly have to respond to complaints and legal proceedings that reflect the patient's persona.
Although of considerable importance, relatively little attention has been placed on the mental processes of surgical patients or how surgeons handle these issues. Much emphasis has been placed on surgeons' communication skills in recent years, but this has not generally included any emphasis on the importance of understanding the patient's mind-set. Better understanding of psychological factors not only prevents unsatisfactory outcomes, like complaints and litigation, but may also lead to better clinical outcomes. In turn, there is the opportunity for a better quality of life for both the patient and the surgeon.
What aspects of psychological understanding might therefore help the surgeon? Surgical practice has benefited tremendously from ideas utilized in aviation. Simulation, team working and the use of checklists have all been widely adopted. In aviation, however, human behaviour models have been successfully implemented to improve performance. A faculty of ‘aviation psychology’ has emerged that deals with psychological aspects of passengers and pilots from cognitive, behavioural and organizational perspectives. Given the similarities in safety cultures, why should ‘surgical psychology’ not contribute to surgery in the same way? As far as the customer needs are concerned, surgical patients have far more needs than airline passengers. Incorporating a psychological perspective in the surgeon's toolkit is bound to improve patient satisfaction. In turn, it will help surgeons gain greater insight into their own performances. In that sense, ‘surgical psychology’ could be considered akin to ‘sports psychology’ in terms of enhancing surgical performance.
The operating room is a complex work environment that can be stressful. Developments in recent years, involving new technologies, increasingly complex interventions and greater scrutiny of surgical performance, all contribute to rising levels of stress that surgeons experience. Although stress can catalyse performance, extreme stress can have harmful consequences. A recent systematic review acknowledged that stress does have a negative impact on surgical performance.
In a study that investigated the impact of stress and coping strategies on surgical performance, most surgeons acknowledged that stress had both positive as well as negative effects and reported that successful coping strategies were positively related to surgical performance. The study also revealed that coping skills were independent of experience, highlighting that those skills are not necessarily acquired automatically. Perhaps this observation identified the need for training in coping strategies to be incorporated into surgical training and as a part of continued professional development? A randomized trial that looked at formal stress management training found that surgeons who underwent psychological training showed less stress and better performance.
Although the patient's mind-set can have serious consequences, the effects of the surgeon's own psychological reactions should not be underestimated. A Swedish study observed that surgeons are at an increased risk of death from ischaemic heart disease compared with the general population. The main difference between surgeons and the rest of the population was their work patterns. The increase in sympathetic activity during surgery may have deleterious effects, ranging from worsening of ischaemia to lethal arrhythmias or sudden death. Despite all this, surgeons for the most part are expected to dismiss the consequences of stress, unlike professionals in other settings. A study in this issue on surgeons' well-being reveals how a postoperative complication can have a serious psychological impact on surgeons. It elaborates on the factors that make surgeons the ‘second victim’ of an adverse event and how the prevailing blame culture exacerbates their injuries. It highlights the need for this problem to be taken seriously as it has long-term consequences on surgeons and their patients' care.
Those who shrug off the issue of stress maintain that surgeons are more resilient than their counterparts in other specialities. Although that may be the case, an anxious doctor may function without any consequence on medical practice, but an anxious surgeon's shaky hands inevitably impair performance.
For these reasons, burn-out among surgeons may be a silent killer. In a large study involving 582 surgeons in the USA, 32 per cent demonstrated significant psychological morbidity. In a study published last year, one-third of 342 consultant surgeons across the specialties in the UK reported symptoms of burn-out. The symptoms were present irrespective of seniority, number of hours worked per week or geographical area. The ramifications of this on surgical performance remain unknown.
Surgeons have generally stayed away from psychological matters. In that sense, they might be equated to ropewalkers. The latter avoid looking at their feet while performing for the fear of falling, whereas it is said that surgeons refrain from looking within owing to the concern of losing control. This stereotype appears to be changing. Understanding the importance of human factors and quality-of-life issues as well as the emergence of multidisciplinary working has lowered the barriers between surgery and human sciences. Implementation of the checklist has changed some surgeons' views about non-technical skills. Checklists at a basic level function as reminders, whereas at a broader level their application relates to a general culture of safety. Safety culture relates to attitudes, thoughts, and behaviours of the individuals, so checklists have the capacity to increase the frequency of positive team behaviours. Their implementation represents a cultural shift that may have been uncomfortable for surgeons initially.
A few years ago a group of experienced surgeons from all over the world gathered to discuss essential attributes of surgical competency. They rated psychological factors as ‘very important’, above technical skills among competency requirements. In 2003 BJS carried a leader encouraging surgeons to be mindful of a cognitive process. Since then, other articles and studies suggest that psychological issues are no longer taboo topics in surgery. A study about psychological impact on surgeons being conducted and published in this journal is evidence that things are moving in the right direction. Surgeons looking at this paradigm shift with a critical eye but an open mind would find it beneficial if this gained further momentum.