It may seem paradoxical that surgeons who rarely work alone, be it in the operating theatre, on the ward round, or in the multidisciplinary team meetings, could be lonely. Surgeons are perceived as stoic, decisive, self-reliant, and infallible under pressure. However, recent literature has started highlighting the loneliness behind that facade of business as usual.1 The US Surgeon General brought this to the fore by talking about the epidemic of loneliness and its health consequences.2 I would argue that there is no epidemic; it is a part and parcel of being a surgeon, and we get conditioned to accept it as a norm from medical school through surgical training. These very qualities of commitment, self-sacrifice, and perfectionism can also put the surgeons at risk of burnout. Time-critical decisions made in a high-stake environment, where life or limb of a patient may be at stake, make surgeons different from other specialists. The moment the surgeon’s scalpel touches the patient’s skin, there seems to be a complete transfer of responsibility, accountability, and attributability for anything that happens to the patient. If a surgical patient dies, the question that is always asked is “what did you do?;” however, if a medical patient dies, the question asked is “what happened?” Surgical loneliness is an inevitable consequence of the profession. Surgical decisions often reshape a patient’s life; they affect the quality of life and survival. A multitude of factors determine the actual surgical outcome, and it is not always dependent upon the technical excellence or lack of it during the procedure. However, there is always one named consultant for the patient, with the solitary burden of ultimate responsibility and limited shared accountability. Surgeons’ loneliness stems from an interplay of structural, cultural, and personal factors. Your results, grateful patients, and peer validation give you an identity and a purpose. You carry on going the extra mile, feeling invincible, but you are leaning on a hollow crutch. Surgery is an all-consuming profession; you invest a lifetime to become a competent surgeon, and all our life decisions revolve around it almost to a torturous degree. Multiple systematic reviews and large cross-sectional studies demonstrate elevated rates of burnout, anxiety, and depression among surgeons.1,3-5 Rates up to 60% have been reported but vary by specialty, career stage, gender, and measurement tool.1,5,6 Systematic reviews of surgeon well-being have noted elevated risk of anxiety, depression, and attrition among surgeons, with key stressors being heavy workload, poor work–life balance, and moral distress related to system constraints.1,6,7 Long hours, fragmented on-call patterns, and night work disrupt family life and reduce opportunities for sustained social interactions outside work. Hierarchical surgical training culture does not help. Strong hierarchies within the department inhibit candidness. Fear of criticism, career consequences, or litigation reduces open discussion of uncertainty and error. Expressing doubt or seeking help is often considered a weakness. Together, these factors generate an environment in which surgeons may have fewer meaningful, candid conversations about their difficult decisions and feelings, fostering loneliness. The cumulative effect of loneliness, moral regret, and burnout may lead to deep, lasting psychological harm and predispose suicidal ideation among some.5-8 Loneliness is not just an emotional experience; it has a significant effect on surgical decision-making. When surgeons feel isolated, opportunities for candid case reviews reduce, and feedback loops are weakened. This impairs reflection and learning from near misses. Lonely surgeons with fewer supportive outlets tend to internalize blame, regret, or moral distress. This leads to either excessive self-doubt leading to risk avoidance and shirking complex cases or to making rushed, uninformed decisions, depending upon personality trait and risk tolerance. The consequences of lonely decision-making extend well beyond the index case. Surgeons often live with the consequences of their decisions for years. They become the second victims/casualties, riddled with self-doubt and guilt.9 Persistent rumination is linked with depression and impaired professional functioning. Isolation and poor well-being are associated with increased likelihood of complaints and disciplinary encounters. On a personal front, loneliness and unresolved distress, strain relationships and family life and increase the risk of substance misuse and suicidal ideation.6,10 The relationship between the surgeon and patient is fundamental, but times have changed. The surgical career is not what it used to be. Patient population is less deferential and better informed (or ill-informed through social media and Internet searches), and there are ever-new treatment options. This makes consultations challenging and the risk of litigation higher if there were to be an adverse outcome. Hospitals react to every adverse event or error as an anomaly and are quick to blame an individual rather than look at systematic improvements that would prevent future errors. The regulatory system and media worldwide seem to work on the premise “Guilty until proven innocent.” To support the surgeons and sustain excellent outcomes with improved patient care, we must build systems that share responsibility and reduce loneliness.11 Strategies to mitigate must operate at three levels: individual surgeons, teams/institutions, and health systems. SURGEON LEVEL STRATEGIES Be kind to yourself: Your physical and mental health matters too Live a healthy lifestyle. Benefits of exercise, diet, not smoking, and avoiding alcohol and drug abuse are not restricted to patients only! Get enough rest. Give yourself permission to take guilt-free rest days and return with renewed clarity and compassion Have a life outside work – See it as an essential part of doing your best work Learn to say no. We tend to put everyone else’s needs before our own Less self-judgment and more reflection: Revisit why what you are doing is important to you. Keep a confidential reflective log (protected and anonymized) to externalize rumination and permit cognitive reframing. TEAM/INSTITUTIONAL LEVEL STRATEGIES Systems to share responsibility: Multidisciplinary decision framework to distribute responsibility and co-signing for extremely high-risk cases Shared decision-making: Patient and family involvement in decisions with documentation of the deliberation process, risk framing, and alternatives; a shared consent with a transparent record of collaborative decision-making Morbidity and mortality formats that emphasize learning rather than blame Active peer support programs: Implement “buddy” systems and mentoring programs. Newly appointed surgeons must have full support to develop their competence and confidence Structured nonpunitive debrief after adverse events. Safe debriefs that focus on learning but also allow emotional processing Targeted professional confidential mental health access. Easily accessible, confidential services, and nonpunitive reintegration pathways with defined return-to-work protocols. SYSTEM LEVEL STRATEGIES (DEANERY AND PROFESSIONAL BODIES) Attention to surgical culture, training, and leadership. Train surgeons in reflective practice, shared decision-making, and cognitive error awareness. Teaching trainees how to handle regret, moral distress, and communication around uncertainty should be explicit components of training Psychological safety culture. Leadership must normalize help-seeking and explicitly oppose punitive responses to reporting Protected recovery time and workload management. Prioritize rest, sleep, and social support. Reasonable on-call schedules and limits on cumulative hours to reduce fatigue. There is evidence from other high-stake professions like aviation and military that structured peer review, pre-brief/debriefs, and psychological support reduce moral distress and improve resilience. Surgical specialties are already adapting many of these practices.12 CONCLUSION Loneliness is a global challenge. There is a need to cultivate collegiality and safety by openly discussing doubt and errors. Transparent documentation of deliberation, seeking senior or multidisciplinary input for high-stake choices, and using formal shared decision frameworks protect both patients and clinicians. Sustainable change requires surgical leadership to cultivate a culture of connection – but at the end of the day, it is an individual’s choice to engage.
Raghvinder Pal Singh Gambhir (Wed,) studied this question.