Mindfulness in clinical practice for surgeons

Surgery requires a unique combination of advanced technical skill, complex decision-making under acute time pressure, the ability to work as part of a team, and the emotional and psychological fortitude to cope with common stressors. Surgeons are in a situation where mistakes can cause permanent harm. The chronic exposure to stressors, including numerous time-pressured choices; cognitive overload; patient mortality and morbidity; medical errors; risk of litigation; high-demand schedules; and the overall aspects of being a surgeon, cumulatively put the profession at risk of psychological distress.

Mindfulness has been a part of ancient contemplative traditions but it has been adapted and secularised to various contexts. Mindfulness, defined by Jon Kabat-Zinn, is: “Paying attention in a particular way: on purpose, in the present moment and nonjudgmentally.” Mindfulness can be defined as the capacity to be aware of your thoughts, emotions, body sensations and environment in general without exhibiting an excessive degree of reactivity or judgment. Mindfulness-based interventions (MBIs) have been found to be effective in reducing stress, anxiety and depression and improving wellbeing in many populations, including healthcare professionals. The focus of this review will be to examine the evolving literature and theoretical rationale for mindfulness in clinical practice for surgeons.

The surgical environment: a crucible of stress and cognitive demand

Understanding the possible benefit of mindfulness requires an understanding of the particular stressors associated with surgery. In addition to long working hours and sleep deprivation, there are the lesser-understood cognitive and emotional challenges that surgeons experience. The weight of internal expectations and external observation creates a significant pressure for all surgeons to perform perfectly. This pressure is often exacerbated for surgical trainees. Stress and fatigue can both diminish an individual’s ability to communicate and increase interpersonal conflict. This combination can generate a workplace atmosphere in which maladaptive coping styles can form and burnout can develop. Traditional methods of support may not suffice.

Mindfulness: theoretical mechanisms relevant to surgery

Mindfulness practices are thought to affect the psychological and physiological processes relevant to surgical demands through a number of interlinked mechanisms. Mindfulness training involves focusing attention (for example, on the breath) and, as the mind wanders, skilfully redirecting it back. It is believed that this modifies and strengthens attentional networks in the brain and may enhance sustained attention, reduce distractibility and increase the amount of time available for switching between focused states in terms of necessary performance. Mindfulness can facilitate non-judgmental awareness of emotions that arise. This ‘decentring’ perspective may lessen emotional reactivity. 

Mindfulness practices have been shown to modulate the physiological stress response, lowering cortisol and reducing activation of several regions linked to stress-processing in the brain, including the amygdala and prefrontal cortex. Regular practice may buffer chronic occupational stressors and reduce the chronic process to burnout. Mindfulness practices build sensitivity to internal bodily sensations, and a greater sensitivity to interoceptive awareness may support individuals in recognising early signals of stress. Mindfulness coaxes one’s perspective to see thoughts as mental events in their own right, as opposed to actual truths. Mindfulness practices are frequently supplemented with forms of kindness and compassion for oneself. This may serve to diminish the self-criticism commonly associated with errors. 

Evidence for mindfulness in high-stress professions and surgery

Research focused on surgeons is still in its infancy; however, the experiences of other high-stress professions and pilot studies with surgeons provides useful insight. Many studies show MBIs are effective for physicians, nurses, and other healthcare workers. Systematic reviews and meta-analyses show significant lower levels of stress, burnout symptoms, anxiety and depression, and increased well-being, quality of life and self-compassion. Research specific to surgeons is increasing. Lebares et al. did conduct a pilot randomised controlled trial (RCT) on a tailored MBI involving surgical interns. The intervention group had significantly lower levels of perceived stress and negative affect. A follow-up RCT with the same group reported continued reduced levels of burnout and improved cortisol profiles after 12 months. Other studies have assessed shorter interventions and mindfulness applications. A brief, online mindfulness intervention for surgical residents showed feasibility and suggested lower levels of stress and improved mindfulness scores. Another pilot study using a smartphone application showed lower stress and burnout among surgical residents. Qualitative studies have also indicated surgeons believed mindfulness might be beneficial for coping with stress.

Potential applications in surgical practice and training

In a surgeon’s professional life, mindfulness concepts and applications can support in many ways:

Preoperative routine. Mindful practice as part of one’s routine before entering the operating room can diminish anticipatory anxiety, assist with attention focus and mental preparation associated with the work in the procedure.

Intraoperative. Mindful awareness can serve to assist a surgeon in cultivating and sustaining elements of focus and attention in prolonged or complex cases, observing subtle changes in the patient or in the surgical field, optimising appropriate distractions, and calming self-care in the case of unforeseen events. Awareness of increasing frustration or pressure during the operation can create recognition that a surgeon may need to step back from the case for ‘a minute’ to re-establish mindfulness.

Postoperative debrief and reflection. Mindful practice may allow a surgeon to hold both the negative and positive outcomes of the surgical procedure humanistically and non-judgmentally to enhance learning from experiences, reduce the tendency to dwell on shortcomings, and promote psychological recovery and re-engagement to the workplace following challenging cases.

Stress management. Mindfulness can happen in ‘micro practices’ throughout the day when navigating moments of professional life –
between cases, during commutes and breaks, or ahead of difficult conversations – to create space that generates physiological calm or mitigates reactivity in the cycle of stress.

Communication and teamwork. Mindful listening and communication may improve the way a surgeon engages with their patient, patient’s family and surgical team to develop understanding, lower levels of misunderstanding and create collaborative agreements.

Challenges and barriers to implementation

As well as advantages, there may be considerable barriers to adapting mindfulness into surgical practice. First, surgeons and trainees are always pressed for time and typically do not have any time available for training in or even practising mindfulness in this busy environment. Any intervention must not be too time consuming or yield a low impact. Second, the prevailing culture in surgery is one of stoicism, technical skill and action-based problem-solving. Furthermore, not all standardised mindfulness interventions account for the various procedural and clinical factors and stressors of surgical work-specific environments. Interventions that invited surgeons to develop the mindfulness intervention programme and where the instructor had knowledge of the clinical environment were seen as more favourable and likely to be more successful. 

Future directions and research needs

To establish mindfulness in surgery in the future, research should be directed toward several important areas. Large, multi-centre RCTs will establish pilot study findings, establish long-term effects and also compare the differences in MBI formats.

Research designs should incorporate objective measures that include (but are not limited to):

• Physiological measures of stress.
• Neuroimaging data to create an understanding of the neural mechanisms of change.
• Validated assessments of attentional control and cognitive functions.
• Objective measures of technical skill in simulated and/or actual operative contexts.
• Possibly, measures of clinical outcomes and patient safety outcomes.

Conclusion

Surgery has high-stress and harmful impacts on the wellbeing and, potentially, the performance of surgeons. Mindfulness is an evidence-based strategy that can potentially assist surgeons in managing and responding to the demands of surgery by facilitating an increased degree of attention, improving emotional regulation, decreasing stress and enhancing resilience to stress. It will be important for research to prioritise reflection paid to methodological rigour and objective outcome measures tailored to the unique context of surgical practice.