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Sustainability in Surgery: Achieving Excellence in Surgical Practice

Surgery is a demanding career with great rewards and equally great challenges. In order to sustain our careers as well as the careers of our colleagues, it is important to understand and address the physical, psychological and spiritual challenges of surgery.

“We are what we repeatedly do. Excellence then, is not an act but a habit.”

William Durant

Surgery is a demanding career with great rewards and equally great challenges. In order to sustain our careers as well as the careers of our colleagues, it is important to understand and address the physical, psychological and spiritual challenges of surgery. With rare exception, the majority of surgeons who prematurely leave surgery do so because they find the work to be physically, emotionally or spiritually incompatible with the vision they have for their life. Understanding these issues and providing solutions to improve surgeon wellness can help prevent societal loss of these highly trained professionals and suffering for surgeons and their families.

“In the classic training program, we have taught how to perform surgery, but we have not taught how to live as a surgeon.”

D Campbell

Although many surgeons truly love their work, 60% of surgeons would retire if they could. The average age for leaving the practice of surgery is less than the expected age of 65 and has been reported to be as low as 57.  This exodus of practicing surgeons is a loss to society, particularly given the significant shortage of surgeons worldwide. It also reflects tremendous personal loss since the most common cited reason for early retirement is burnout. Four dimensions play an important role in understanding the challenges surgeons face and developing strategies for a rewarding career in surgery.

1. Physical well-being

Some illnesses that limit a surgical career are unexpected and not preventable, but others are easily detected and effectively treated with appropriate use of healthcare services. More than 25% of surgeons over 50 fail to schedule a screening colonoscopy, cardiac exam, and, for the men, a prostate examination.

“Sadly, a surgeon can much more easily obtain a detailed ergonomic assessment and direction for improvement of his or her golf swing than of his or her surgical “stance” or movement.”

A. Park

Performing surgery is physical work and therefore has associated specific work-related injuries. In general, the factors that increase the risk of musculoskeletal injury are awkward body posture, frequent repetitive movement of the upper extremities, and prolonged static position. The focus required during surgery results in particularly long periods of time in a static position, greater than that is seen in most other professions.  

There are also numerous design issues that contribute to the ergonomic stresses of surgery. Primary among them is that the operating room design has not significantly changed in the last 50 years. Most operating room tables were designed for open procedures. They are adjustable between 72.5 and 121.5 cm, and therefore do not go low enough for an ergonomically appropriate position for minimally invasive procedures, particularly if the patient is obese.

The instruments and monitors used for minimally invasive surgery can also be problematic as they were initially modified from instruments used by otolaryngology. For example, the traditional “tower” configuration of monitors used in otolaryngology is a significant ergonomic issue for minimally invasive surgeons since the screen should always be in front of the surgeon and not to the side. Not being able to move the monitors to this position increases the risk of neck injury.

The handles for instruments used in minimally invasive surgery come in only one size, compared with eight sizes of surgical gloves, a fact that creates issues for surgeons with smaller hands (glove size ≤ 6.5). In addition to being an awkward size for many surgeons, instrument handles often require non-ergonomic motion, particularly for surgeons with smaller hands.

Finally, because of length and other design requirements for laparoscopic instruments, 4 to 6 times more force is required to use these instruments when compared to instruments used in open surgery. The lack of smaller instruments and this need for increased force places women at particular risk for instrument-related ergonomic injury. Solving these ergonomic design issues requires collaboration between manufacturing companies, engineers and surgeons, a process that is now underway.

Exercise plays a particularly important role in the prevention and treatment of musculoskeletal pain from ergonomic injury. Of all forms of exercise, strength training is shown to have the most improvement in musculoskeletal pain in the first two months of exercise, which continues to improve with continued exercise, and persists over time. Yoga, Tai Chi and Pilates may be particularly good exercises for surgeons since they require core strength through rotational movement. The role of exercise in maintenance of health cannot be over emphasised.

Sleep deprivation and chronic sleep restriction are major contributors to poor health and loss of well-being. For surgeons who take a call and experience sleep deprivation, the issue is not only loss of sleep, but an inability to “catch up” on lost sleep. Adults require 8 hours of sleep a night, with only a small percentage who do well with 7 hours of sleep. However, 60% of surgeons reported an average of less than 6 hours of sleep per night, resulting in chronic sleep restriction. Being on call and working the next day was the norm for previous generations, but based on these data this schedule may not lead to optimal patient care. The use of caffeine to counteract sleep deprivation may also be problematic, since increasing amounts of caffeine can negatively affect surgical performance.

“Surgeons share an unwritten but understood code of rules, norms, and expectations. This code includes coming in early and staying late, working nights and weekends, performing a high volume of procedures, meeting multiple simultaneous deadlines, never complaining, and keeping emotions or personal problems from interfering with work. These are hallmarks of dedicated professionals that should be celebrated and rewarded. However, there is a fine line separating dedication from overwork; if unchecked, overwork could lead to counterproductive, unhealthy, or even self-destructive behavior that may affect patient care.”

CM Balch

2. Emotional well-being

Practicing surgery is not easy, and most who choose to be surgeons know and embrace this fact. The act of operating on another human being is stressful, and requires psychological fortitude as well as skill. As a result, the surgeon-patient relationship is unique, and results in deep and special bonds with patients. The surgeon-patient bond is accompanied by a strong, culturally reinforced sense of responsibility. The unspoken implication is that surgeons are responsible for all that happens after a procedure and therefore should be available at all times. Unfortunately, as a result, those who seek time to rest or are suffering for any reason (physical, psychological or spiritual) often feel that they are somehow “less”.
Additional stressors for practicing surgeons include medical errors, adverse outcomes and malpractice lawsuits, all of which are associated with an increased risk of burnout and depression. In these situations, the surgeon inevitably becomes a “second victim” as a result of emotional trauma.

This trauma adversely affects the ability to work, particularly in the areas of memory, recall of knowledge, and attention. Becoming a “second victim” is not an uncommon situation. All physicians experience errors and adverse outcomes. 42% of all physicians will be sued during their career, a number that increases to 90% for surgeons. Focus therefore on emotional integrity by protecting and nurturing important relationships; use debriefing strategies with trusted friends and family after stressful events; and seek professional help for symptoms of depression or anxiety.

3. Burnout

“Burnout” is characterised by a combination of losing enthusiasm for work (emotional exhaustion), viewing and/or treating patients and colleagues as objects (depersonalisation) and nurturing the feeling that others could do your job better than you (low personal achievement). Burnout occurs in all specialities, but is particularly prevalent in the surgical specialities with up to 42% of surgeons meeting the criteria for burnout. The incidence of burnout for all physicians has increased over time, which can be attributed in part to changes in the delivery of medical care which have increased job stress without increasing job satisfaction.

All physicians will experience some or all of the components of burnout during their career. The key is to recognise these symptoms when they occur and intervene quickly and effectively. The first step, which may fly in the face of surgical culture for many surgeons, is to acknowledge this is real, and not a sign of personal failure. Individuals can then experiment with different interventions and strategies for physical, emotional and spiritual self-care.

It is important to not be isolated; “Human beings heal by telling stories.” Having a safe space to “debrief” by sharing the events of the day cannot be overemphasised as a tool in preventing and treating burnout. Therefore, protecting and nurturing close relationships at and outside of work is an essential component of physician self-care. Mindfulness, other meditation practices and/or religious practices are also effective tools in preventing and treating burnout. Physicians who practice mindfulness and learn mindful communication show improved overall burnout scores as well as improvement in each of the three domains of burnout (emotional exhaustion, depersonalisation and achievement).

“Burnout is not a problem of people but of the social environment in which they work.”

Our goal as a profession should to be identify personal or career limiting issues in our colleagues and ourselves early enough to prevent suffering and, if not recognised, true tragedies. We should also work together to change our environment and our culture to promote and encourage self-care and health.  

4. Spiritual well-being

Human beings have a need for meaning in their life and their work. Spirituality provides the context for that meaning, and is an essential part of human wellness. Burnout, often described in emotional terms is also a spiritual malady, “a deterioration of values, dignity, spirit, and will.” The importance of spirituality is recognised by surgeons. Along with protected time for relationships, surgeons rank meaning in work and “focusing on what is most important in life” as the most essential strategies to promote wellness. The perspective gained and tools learned through a spiritual practice allow physicians to gain control by changing their perspective, which may be the single most powerful antidote to physician stress and burnout. Developing a spiritual strategy to deal with the pressure and stress of work can lead to seeing work as not a place where energy is expended, but a place where renewal can occur though the meaning and challenges encountered every day.

The importance of true rest, not just for physical recovery but as a spiritual practice, cannot be overstated. Taking a full day, or even a half-day, to just play, rest, and relax is amazingly restorative. Taking a “digital time out” can be an important part of recovery from work. The constant stimulation of the digital world we live in can compound the stress we feel at work. Finally, taking the vacation days that you are given should be considered important ways to improve spiritual well-being.

The practice of surgery offers the potential for tremendous personal and professional satisfaction. Few careers provide the opportunity to have such a profound effect on the lives of others and to derive meaning from work. Seen through the lens of spiritual self-care, times of stress can be viewed as a moment to step back, an opportunity to evaluate priorities or even a time of professional growth. In this context, a bad day (or longer time period) is not necessarily a sign of burnout, but may be a sign to focus on renewal.

Conclusion

The art of surgery requires surgeons to be physically, emotionally and spiritually sound. Surgeon well-being should therefore be both an individual and institutional priority. Individually, surgeons should consciously develop plans for well-being that incorporate aspects of physical, emotional and spiritual self-care. Surgical groups should develop curricula and ensure that the principles and practice of self-care are taught and understood. These principles include attention to routine health care, exercise, healthy food, ergonomics, sleep and adequate rest as well as the presence of trustworthy friends to share struggles and joys.

Institutions should develop proactive plans to support personal wellness such as insuring comfortable places to rest, eat and talk and providing healthy food in the workplace. All surgeons and administrators should work to develop policies and a culture that recognises the importance of appropriately limiting time in the hospital, supporting individual efforts at self-care, and providing the time for genuine renewal.

These are the eternal duties of a Physician: First … to heal his mind and to give assistance to himself before giving it to anyone else— Epitaph of an Athenian Physician, 2AD

By adhering to this advice, a surgeon could achieve clarity of purpose and focused attention—the essence of excellence.

Professor Ali Al Dameh is the Conference Chair of the Surgery Conference scheduled to be held from 29th January to 1st February 2018 at the Arab Health Congress.

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