Reducing stress in the operating room: stress relief for the surgeon

This column is one in an invited series by Dr. Osher. The series highlights techniques that may be helpful particularly to young practitioners. When I was recently invited to write a chapter on reducing stress in the operating room, my first thought was that I needed to read this chapter rather than write it! After my pulse returned to normal, I began thinking about some of the ways I have reduced my own stress, and as a result, my favorite time of the week is when I am operating. In fact, the operating theater is my sanctuary where I feel most comfortable and happy. I do not mean that I am jovial and carefree, just the opposite. I welcome jokes and laughter between or after the surgical cases but never during. I am serious and laser focused. We know that trouble can occur the moment our attention drifts. But intense concentration is not synonymous with stress, which can hamper rather than help the surgeon. The following tips are principles and practices that I have adopted over my career, which spans more than 4 decades of performing cataract surgery.1 This first article pertains to the surgeon and will be followed by a separate article on reducing patient stress in the next issue of Journal of Cataract & Refractive Surgery. Purpose Every day, I am thankful that I am able to perform a surgical procedure that helps a patient recover clear vision. This mission is meaningful and makes my life fulfilling. I do not view surgery as a business but rather an opportunity to restore the gift of sight. Purpose by itself should mitigate stress. One could easily convert this high-stake responsibility to the fear of error or anxiety in the operating room, but, instead, great responsibility must be upheld as a gift, a mission, or a motivator. Fear has no benefit in the operating room, so scrub it off before entering and focus on the joy of helping others. Preparation There is no substitute for being well prepared. I have practiced critical surgical maneuvers over and over to reach the full potential of my dexterity. I have watched hundreds, no thousands, of videos, which gives me the confidence to know that I am providing the patient with the best procedure I am capable of performing. Moreover, I have read about and watched nearly every video on complication management. I feel prepared to handle a torn capsule or positive pressure. I have rehearsed with my staff what we need to do urgently if the nucleus starts to descend, and my team is highly competent in mobilizing the vitrector with my preferred settings. I use multiple intraocular lens (IOL) formulas and select the lens myself, carefully monitoring the result in the first eye to facilitate accurate lens selection in the fellow eye. When you know the patient, know the procedure, and know how to handle any potential complications, you can minimize stress. Team When I walk into the room and see the familiar faces of the circulating nurse, technician, and anesthetist, I immediately feel relieved. The anesthetist knows that I like to keep the patient very light, so I can easily converse during the surgery. The scrub techs are familiar with the sequence of my surgical steps, and they know my preferred instruments, which they have personally cleaned and checked to make certain that nothing is missing or broken. The circulating nurse knows which medications I use, how to set the temperature and the room lighting, and where I like the bed to be located in relation to the microscope. They even know the type of music I prefer. An experienced team does wonders for reducing stress. When you have new staff, take extra time ahead of the case to familiarize everyone with the plan and your preferences. Equipment and Instrumentation I briefly mentioned instrumentation, but this is very important and deserves emphasis. A missing or broken instrument or new unfamiliar instrumentation, equipment, or technology can cause terrible stress for the surgeon. This also applies to the IOL inventory, so having backup lenses available relieves the concern about encountering a defective IOL. Ensure your management staff knows that surgeons require familiarity and must receive ample notice and/or practice to become comfortable with new tools. Music I clearly recall fighting the strict hospital policy in 1980 when I tried to introduce music into the operating room. I brought my own boom box that we had to hide the moment an administrator was sighted. Fortunately, several studies have shown that both the patient and the surgeon are more relaxed when there is music in the background.2 I try to select songs in the category of soft listening. Patient Load Allowing for extra case time, especially when you are junior, will reduce your stress when trying to move quickly to stay on time. I used to schedule as many patients as possible, and I always felt under a great deal of pressure. Eventually, I realized that it was far less stressful to schedule fewer patients and add a few extra minutes for each case. When there is an interruption, a rare complication, or a challenging case that requires a bit more time, I am grateful for that time buffer. If the day goes smoothly, I can spend extra time with patients, staff, family, or enjoying a hobby or project. Clearing the Deck Juggling multiple tasks or wearing multiple hats can be desirable but should not be carried into the operating room. Get rid of as many distractions as possible before surgery. Simple yet burdensome tasks (eg, emails, phone calls, and dictations) should be completed ahead of time. This removes an invisible yoke from the surgeon's neck. If you must save a task for later, write it down and remove it from your mind. Getting rid of mental “noise” allows the surgeon to focus and enjoy the peace and calm of the operating room. Schedule After Surgery The same logic applies to the never-ending list of postoperative obligations. Avoid scheduling important engagements immediately postoperatively. Stress is inevitable under these circumstances. It is far wiser to schedule important meetings and events at a different time. Expert Support If Needed One of the greatest sources of equanimity that I have enjoyed over the years has been the feeling of security in knowing that I am surrounded by the expert support of my partners. Although dropping a nucleus is certainly stressful, it is reassuring to know that I have a dozen retinal specialists in my group who are available to rescue the case. Every surgeon is going to encounter complications, but stress can be reduced by knowing that an expert is nearby. Regardless of whether the surgeon is in a solo or group practice, a relationship with other subspecialists should be nurtured in case help is needed. Eliminate Battles and Conflicts Controversy is ubiquitous. It is human nature to have disagreements, differing opinions, and even confrontations that are very unpleasant. There is no place for professional or familial distractions on a surgery day. Trying to concentrate on an operation while trying to resolve a conflict is unacceptable in the operating room. Make peace whenever possible before the incision. Life Balance I authored a book titled The Real ABCs: Achievement, Balance, Contentment.3 It is important to work hard and also to play hard. This editorial has concentrated on reducing or eliminating stressors, but maintaining physical and mental health can help manage the residual, inevitable anxiety that every surgeon will face. We must learn to properly cope with and even thrive in the face of moderate pressure. When we nurture healthy relationships with loved ones, we are less likely to compound stress. By working to find balance and contentment in our lives, we can more completely enjoy the privilege of serving as the guardians of sight, even when it comes with some degree of stress.