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Stress in the OR: Origins and Solutions
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By Elizabeth Hofheinz, MEd, MPH
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July 24, 2007
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Stress. No one gets through life without it. Rest assured that it will either creep up or appear suddenly, often at the most inconvenient times ... like when you have a patient open on a table. Wayne Sotile, Ph.D., stress expert and consultant to the medical profession, has worked with thousands of physicians. Despite the prevalence of stress in medicine—and in orthopedics in particular—Dr. Sotile remains positive: “In one’s darkest, most worrisome moments, stress can seem insurmountable. There are antidotes, however, that if used regularly, can significantly reduce anxiety and smooth out the flow of one’s days.” Do tell. “One of the primary ways to manage stress is to have frequent ‘states of excellence,’ i.e., rewarding, exciting moments that feel important,” says Dr. Sotile. “The idea is to counter daily hassles with daily uplifts, whether that’s humor, a philosophy that reminds you of the goodness of your work, or a degree of personal fortitude. The primary issue is to maintain caring connections with people. But young orthopedic surgeons often don’t realize that it requires more than technical proficiency to achieve and maintain a state of excellence. My work has shown that those who most enjoy the orthopedic OR for a lifetime are the ones who pay attention to creating teamwork. A number of studies have found that in order to consistently get positive outcomes, it’s important to be respectful of and communicative with one’s collaborators. Doing so is one of the best ways of assuring that the uplifts of the day will counteract the hassles.” So everyone wants to sign up, right? Not exactly. Says Dr. Sotile, “Contrary to the stereotype, the older orthopedic surgeons tend to ‘get it’ about teamwork. I believe this is largely because of their stage of psychological development. They have had time to incorporate an awareness and appreciation of the people around them. There are two cohorts that need to learn about teamwork. Actually, the ones who have the most problems with teamwork are those who are angry about the changes that have happened in medicine, and those who are new to the dance. In the first case, I’m referring to those middle-age surgeons who feel double-crossed about the way that medicine has changed. The other group that has a problem in this area are the supersonically trained young surgeons who are still driven by technical proficiency. Becoming technically proficient and developing task-specific self confidence is great for the short term, but it doesn’t last and can leave a surgeon feeling like something is missing.” Yes, even in a nuts-and-bolts profession such as this, those messy “feeling” things abound. States Dr. Sotile, “Another issue regarding long term resilience and stress management is staying engaged. To be supremely successful, one should develop the psychology of focus. I have discovered that many physicians react just like everyone else in this regard. They think, ‘No matter where I am, I feel anxious about wherever I’m not.’ In two of our three surveys of orthopedic surgeons on work/life balance, the data told us that it’s not so much the number of hours worked that stresses them out, it’s the mismanaging of emotions and relationships that does them in. This suggests that to the extent that work concerns invade the home, the quality of life at home is reduced. And when home concerns interfere with one’s focus on work, burnout increases. My advice is this: when at work, be at work.” Continues Dr. Sotile, “We have found how anxiety-provoking it is when surgeons are at work and are worried about what’s going on at home. For example, I was hired by a practice to help with teamwork, and discovered that much of the discord was being driven by a surgeon who was burning out and who had developed some problematic behaviors. He was routinely receiving 10 – 15 calls from his wife during surgery and the nurse was being asked to hold the phone to his ear. He was clearly unfocused and heading downhill. In fact, our research shows a direct correlation between the amount of contact with home while at work and a high level of stress. Emotions are contagious and if something is going wrong at home, the doctor will pick up the stress ‘ball’ and carry it. In this case, the wife was unhappy, which made the doctor unhappy, and ultimately, the group was unhappy.” If a surgeon is able to focus at work, however, he or she is more likely to experience a bit of bliss. “Most orthopedic surgeons find it relaxing to operate,” says Wayne Sotile. “This makes sense because it’s a high-demand, high-control situation, something that’s been shown by research to be soothing. Specifically, one’s blood pressure lowers, autoimmune system functions regulate, etc. If, however, one is in a low-demand, high-control situation, that is usually boring. And a high-demand, low-control situation is just toxic. For example, if it’s a high-demand situation, like surgery, but there is a team member the surgeon perceives to be incompetent, they may have little control over that in the moment. Anything that interferes with efficiency is going to be frustrating and stressful for a surgeon. We are just beginning to teach orthopedic surgeons how to develop people and how to be an executive level leader. While the old-school iron fist is still around, it doesn’t have sustainability. A classic scenario is an angry orthopedic surgeon blaming the hospital administrator for not being effective in training nurses or getting the right anesthetist. ‘Give me a better team!’ they’ll say. The better solution is usually to train the doctor in a bit of people development.” Yes, says Dr. Sotile, most times what burns doctors out falls in the “We weren’t taught this in medical school” category. “Let’s say a surgeon has an incompetent person who is refusing to learn how to work with them. First of all, you shouldn’t wait for someone else to solve the problem. You should focus your intellectual horsepower on people development. Think about it: don’t you have 10 – 20 minutes a day to manage the people who are going to make your life more or less miserable? Even small points of contact are helpful. Do things that recognize the contributions of each member of the team. That way, when it comes time to teach/guide them, they will be more open to being taught. I love the example from FedEx. A highly placed executive was accustomed to saying positive things about his secretary, but one day he left in a hurry. It was raining buckets as he headed down the highway, but he suddenly realized he had forgotten to thank his assistant. Surprising his colleague and passenger, he turned the car around, went back to the office, and thanked everyone who had made his day easier. It is very true that one’s ancillary staff wants to forgive you if you have cranky day. And they’ll be more likely to do so if you’ve built up some consistent goodwill.” Aside from those in the office, for many surgeons the surrounding environment or structure is stressful. “Every surgeon has his or his unique work capacity, style, and speed. If the institution where you are employed is driving you to work at a style and pace that is not your own, it can be maddening. Some hospitals, for example, drive people to do more surgery than they’re comfortable with. On the other hand, some people are more relaxed by busyness. It’s important that you try to negotiate with the hospital on these issues so that you can gain a better level of comfort and control.” And if that’s not possible? “Try to develop control in other ways,” recommends Wayne Sotile, “First of all, it’s a good idea to develop an ethic of selectivity as you mature. This means choosing more mindfully to do those things for which you are highly skilled, and for which you have a lot of passion. When first starting out, an orthopedic surgeon typically sees anybody. At some point, however, you should focus on things that sustain your passion. Just because you have a great reputation on certain surgeries, you should reinvent yourself if you feel stale. While not all of the workflow is under your control, there are certainly new techniques to be learned and ideas to investigate.” Always striking a hopeful note, Dr. Sotile’s message is that the very nature of what orthopedic surgeons do involves positive outcomes. “The fundamental decision that surgeons make is a positive one, namely, the decision to help people. I think the issue is, however, that surgeons need to give themselves permission to take care of themselves. The field doesn’t give that permission, so doctors need to give it to themselves. Also, it’s important to know that when you have a negative outcome, you need to do a stress debriefing. Get support from your colleagues or loved ones and create rituals that allow you to decompress. Whatever you do, don’t allow yourself to accumulate stress. One surgeon told me that he had built up so much stress that he started having tantrums, drinking, and finally spent a year crying when a patient died.” Wayne Sotile, Ph.D., is co-author of The Resilient Physician (AMA Press, 2002) and co-author of Letting Go of What’s Holding You Back! (Stewart, Tabori & Chang, 2007). For further information, visit his web site, www.TheResilientPhysician.com.
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