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Is There an Apgar Score for Surgeons' Stress Levels?

Students of medicine know there exist many systems for scoring, grading, and staging disease states. Some of these systems have proven to be exceedingly beneficial. Well-known examples include Apgar Scores, the Glasgow Coma Scale, organ injury grades, tumor grades, and staging of cancers. Others are arcane and useful only in certain specialties.

Much has been written about physicians and stress. Wouldn't it be useful when discussing stress to flip the script and let the physician be the patient? More specifically, I am thinking about surgeons and surgical stress. Once anesthesia has been induced and the operation begun, surgeons, I believe, are able to block most (if not all) external distraction. Think of the painter en plein air for whom there is only canvas, light, and landscape. I use this analogy because surgery is sometimes described as art. Or, for the mathematically inclined, think of the surgeon in the operating room as an initial condition in a system to be modeled. Given this condition, I posit four stages of Surgical Stress for the operating surgeon:

Stage I

Patient is stable prior to and throughout the surgical procedure. The difficulty of the operation is inherent to the procedure being performed.

Stage II

Patient is unstable preoperatively, or patient instability is imminent and expected. Examples of such patient conditions are major trauma and sepsis. These cases are dramatic (and probably represent the stereotypical examples of how many lay people imagine surgeons and the craft of surgery).

Stage III

Patient is stable with an expected satisfactory outcome from surgery but becomes unstable during the operation. An example might be major bleeding during mobilization of a tumor or air embolism. This Stage often requires immediate and decisive action by the surgeon.

Stage IV

Patient is stable during the procedure but has a significant complication. Patient may or may not then become unstable. Surgeon is possibly (or definitely) at fault. An example is common hepatic duct injury during laparoscopic cholecystectomy.

In the proposed staging system, the level of stress increases as one progresses. The Yerkes-Dodson Law tells us that the relationship between stress and performance is a bell-shaped curve. Thus, the effect of stress on performance is a lot like caffeine, some is good but too much is bad. Stage I – and even Stage II – stress is in the surgeon's comfort zone. Stage III – and especially Stage IV – stress may push the surgeon beyond the inflection point on the Yerkes-Dodson curve. At these higher stages, dexterity and cognitive ability can and do decline. Even for very experienced surgeons, sympathetic arousal (increased heart rate, increased blood pressure, pupillary dilatation, perspiration) is triggered.

In any operative crisis, the goal is to avoid tilt. Tilt is described by professional poker player Annie Duke in her book “Thinking in Bets” as "the concept that a bad outcome can have an impact on your emotions and compromise decision-making going forward." The initial step to limiting tilt and harnessing sympathetic arousal is to acknowledge that discrete stages of in-operating room stress exist. Indeed, surgeons are not always able to operate in their comfort zone. Any surgeon with significant experience will one day (or maybe one night), find themselves operating with what I have labeled Stage III or Stage IV surgical stress. But hopefully, after reading this short treatise, that surgeon will be more prepared when that stress comes.


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