As the old adage goes, “No pressure, no diamonds,” and we see that play out all the time in the real world. We see sports teams execute plays perfectly in the final seconds of a close game. We see students hone their focus when taking a mid-term test. A little stress can hone our focus and allow us to trust all the work we’ve put in ahead of time. When we think of it this way, a little stress in the operating room can be a great thing.

Stress During Surgery

A recent study out of Lyon wanted to get a better understanding of how stress impacts surgeons and procedural outcomes. For the study, researchers tracked heart rate variability (HRV), specifically the low-frequency to high-frequency (LF/HF) ratio, which reflects sympathovagal balance. HRV was measured for the first five minutes of an operation across a total of 793 surgeries.

After looking at the results, researchers found that increased surgeon sympathovagal balance during the first five minutes of surgery was associated with significantly reduced major surgical complications. A non-significant reduction in ICU stay and mortality were also observed. The findings suggest that increased surgeon stress at the beginning of the procedure was associated with improved clinical outcomes. Researchers also pointed out that this increase in stress was simply due to the surgical undertaking, and not due to an unexpected event or complication with the procedure.

Dr. Silverman Comments

I track by heart rate variability and stress every day. Similar to many of the surgeons in this study, my stress level increases during surgery. My Whoop activity tracker has the ability to track a whole laundry list of physiologic factors, and it allows me to see how my stress levels fluctuate throughout the day. It also has the ability to send reminders to practice breathing exercises or relaxation techniques when it notices I’m showing indications of stress.

Heart rate variability is an interesting measure to track, especially because I was once told that “surgeons have higher heart rate spikes on the golf course than in surgery.” And while I’ve never actually seen that study, that notion makes some sense when we apply the findings in this study.

At a very basic level, surgery is much more stressful than golf, so how can the above statement be true? As we noted above, a little stress can be a good thing because it can force us to focus and rely on our training. I’ve dedicated most of my life to improving my understanding and my skills as a surgeon, and while that doesn’t change the stakes of surgery, it has left me completely prepared to carry out the task at hand. That stress we feel at the beginning of surgery is a good thing, and it allows us to better focus at achieving the best outcomes because we lean on the decades of experience that has led up to this moment.

Conversely, I can count on one hand how many times I’ve tried to split a pair of trees and land the perfect shot with a 7-iron onto a down-sloped green surrounded by sand traps. The stakes are much lower compared to surgery, but given my lack of experience in this arena, being in this position certainly would cause a spike in HRV, and I wouldn’t have past successes to fall back on in the moment. It’s certainly possible that this moment would in fact feel more stressful than the first few minutes of a procedure to a trained surgeon.

With that said, golf isn’t my preferred outlet when I’m not in surgery. I’d much rather find a gateway to relieve stress than to take on a hobby that may end up bringing on an even larger stress burden. This is why you’ll find me at the Crossfit gym, not the golf course when I’m looking to relax and destress!

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Foot surgery is one of the main reasons why patients seek out Dr. Silverman for care, which is why we thought it would be beneficial to start a series that dives into a number of important aspects of the foot surgery process. We want you to be well-informed before you move forward with surgery and after the operation is complete, and we think this series can be an incredible resource for doing just that. We continue the series by looking at some of the ways that stress can impact your likelihood of a successful foot and ankle surgery.

The prospect of surgery can leave your feeling anxious or stressed, but this mental anguish can actually have a physical effect on the success of your surgical operation. It’s important to work to reduce stress prior to your operation, but we know that’s easier said than done. Below, we explore how stress can impact your surgical success and how you can work to reduce stress before and after your operation.

How Stress Impacts Your Body

Stress and anxiety activates your body’s natural fight or flight response, which also induces a number of physical changes in our bodies. Our pulse rate increases, our blood pressure changes and our immune system can become hypersensitive, increasing a person’s risk of issues like:

• Arrhythmia
• Immune dysfunction
• Hyperinflammation
• Organ dysfunction
• Increased post-op pain

The last bullet point is especially relevant, as previous studies have found that greater levels of post-op pain are linked or a host of negative outcomes, like prolonged recovery, impaired wound healing, decreased patient satisfaction, longer hospital stays, increased patient costs and even elevated mortality rates.

How To Reduce Stress Before Surgery

Controlling stress ahead of an operation is just one of the many ways you’ll want to work towards becoming the healthiest version of yourself prior to surgery. You’ll also want to pursue some physical therapy, improve your diet, get quality sleep and manage your medications appropriately. As for managing stress ahead of surgery, some of the best ways to do that include:

Yoga – Studies have found that as little as 20 minutes of yoga a day can help to reduce inflammatory markers in the body. Yoga incorporates physical movements with relaxation, breathing and mindfulness techniques to help improve your flexibility and reduce stress levels.

Ask Questions – Stress oftentimes originates from our fear of the unknown, so the more you learn about your procedure and what you can do to increase your likelihood of a successful surgery, the less stress you’ll have about the upcoming operation. Understand why you’re undergoing the procedure, how it’s designed to help and what you can do to get the most out of your recovery, and you’ll find that you aren’t as stressed about surgery. If you have any questions, reach out to your surgeon or your care team.

Reframe Your Mindset – We always tell our patients to try and focus on the positives as they head into surgery. Think about all the things you’ll be able to do again assuming the surgery goes as planned and you make a strong recovery. Instead of thinking about what could go wrong, focus on the quality of life improvements you’ll experience assuming everything goes as it should.

Control What You Can Control – Finally, surgery can leave you feeling stressed because you may feel like you have no control over the outcome. While you can’t control every aspect of your operation, there are plenty of things you can do to improve your likelihood of a successful outcome. Check out that post for more information on managing the controllable aspects of your health prior to surgery.

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This idea led researchers to see if there were things that could be done to help ease anxiety and relieve stress in patients who were awake during a surgical procedure. They thought that playing music or having an assistant converse and distract the patient could better help reduce anxiety compared to the standard level of care which doesn’t involve any patient-focused techniques. Interestingly, their findings told a different story than what they expected.

To Distract, Or Not To Distract?

While they didn’t expect music or other distraction techniques to fully rid patients of anxiety and stress during surgery, they did expect the techniques to prove more effective than the absence of any technique. What they found was that the most effective care guideline was based on individual preference.

It may not seem all that shocking that patients had individual preferences, but the findings should help doctors provide better care for patients going forward. For example, when looking at the data, researchers found that music and distraction techniques during a surgical procedure helped calm stress and relieve anxiety in some patients. Other patients found the music and distractions unhelpful, and they actually said that the techniques created additional stress because it became harder to attend to the activities of the surgeon and the medical procedure.

So while it shouldn’t come as a surprise that patients had their own preference during surgery, the findings suggest that care providers should have a conversation with their patients prior to their procedure about how they can help keep the patient calm during surgery. Some patients may want to listen to music or have a conversation with a staff member during the procedure, and others may want to focus on the procedure. Doctors and patients should also discuss some options if the current method is not providing the anxiety relief that they had hoped.

So when it comes to reducing anxiety during a surgical operation, everybody is different. If you need to have a minimally invasive procedure performed and you’ll be awake during the operation, talk with your surgeon about how you’d like to pass the time during the procedure. Dr. Silverman and his team will do everything in their power to make your procedure as comfortable and stress-free as possible.

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Improving the quality of care doctors provide to their patients was the focus of a recent study published in the Journal of Bone and Joint Surgery. For the study, the authors were interested in seeing how time spent with or without the patient affected that patient’s perception of empathy. For example, if a patient waited in the waiting room for 20 minutes and then saw the doctor for 10 minutes, would they be more likely or less likely to rate their doctor as empathetic compared to someone who waited for 5 minutes in the lobby and saw the doctor for a half an hour.

Quality Time With Patients

After looking at the data, researchers were a little surprised with the results. They found that neither variable – time spent in the waiting room and time spent with the doctor – had an impact on their perception of the doctor’s empathy towards their situation. This is interesting, because a lot of doctors believe that patients want to wait less and have more time with the doctor. While this sentiment may be true, study authors found that those factors had no impact on the patient’s perception of empathy from the doctor.

However, researchers did find that there was a direct, inverse relationship between the doctor’s self-reported stress level and the patient-perceived empathy. For every 1-point increase in a surgeon’s self-reported stress (measured by the Perceived Stress Scale), there was a 0.87 decrease in perceived empathy (measured with the Jefferson Scale of Patient’s Perceptions of Physician Empathy).

Essentially, a quality interaction is more important than a short wait time or more time spent with the doctor, and a physician’s stress level appears to have a direct effect on their ability to provide their patient with a quality interaction. So if doctors can work to lower their stress levels, which admittedly is easier said than done, we may be able to provide our patients with a more meaningful visit.

Helping each patient is important, but letting them know that they are important to us is just as crucial during the care process. When we’re stressed, our patients suffer, so doctors need to work on lowering their stress levels for their sake and for the sake of their patients.

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