Original Investigation
January 15, 2025
Association Between Surgeon Stress and Major Surgical Complications
Jake Awtry, Sarah Skinner, Stephanie Polazzi, et al
JAMA Surg. Published online January 15, 2025. doi:10.1001/jamasurg.2024.6072
Question Is surgeon physiological stress, as deduced from the sympathovagal balance measured via heart rate variability analysis, associated with patient outcomes?
Findings In this cohort study including 38 attending surgeons and 793 patients, increased surgeon stress in the first 5 minutes of surgery was associated with a significant reduction in major surgical complications after controlling for patient, surgeon, and surgery characteristics.
Meaning These results suggest that optimizing surgeon stress may offer an avenue to improve surgical performance, with increased stress benefitting patient outcomes for experienced surgeons.
Abstract
Importance Surgeon stress can influence technical and nontechnical skills, but the consequences for patient outcomes remain unknown.
Objective To investigate whether surgeon physiological stress, as assessed by sympathovagal balance, is associated with postoperative complications.
Design, Setting, and Participants This multicenter prospective cohort study included 14 surgical departments involving 7 specialties within 4 university hospitals in Lyon, France. Exclusion criteria consisted of patient age younger than 18 years, palliative surgery, incomplete operative time-stamping data, procedures with a duration of less than 20 minutes, and invalid surgeon heart rate variability (HRV) data. Data were accrued between November 1, 2020, and December 31, 2021, with 30-day follow-up completed on May 8, 2022. Analyses were performed from January 1 to May 31, 2024.
Exposure Sympathovagal balance of the attending surgeon in the first 5 minutes of surgery.
Main Outcomes and Measures Major surgical complications, extended intensive care unit stay, and mortality within 30 days, after adjustment via mixed-effects multivariable logistic regression for surgeon age, professional status, the time of incision, the random effect of the surgeon, and a composite risk score incorporating patient comorbidities and surgery characteristics. Sympathovagal balance was quantified by the low frequency to high frequency (LF:HF) ratio derived from HRV data measured by chest monitors worn intraoperatively. The LF:HF ratio was normalized at the surgeon level to the median value observed for each surgeon during the study period to control for baseline differences.
Results A total of 793 surgical procedures performed by 38 attending surgeons were included in the analysis. Median patient age was 62 (IQR, 47-72) years, and 412 (52.0%) were female, with a median of 2 (IQR, 1-4) comorbidities. Median surgeon age was 46 (IQR, 39-52) years, 39 (78.9%) were male, and 22 (57.9%) were professors. Median surgeon heart rate was 88 (IQR, 77-99) beats per minute. Median surgeon LF:HF ratio was 7.16 (IQR, 4.52-10.72) before and 1.00 (IQR, 0.71-1.32) after normalization. Increased surgeon sympathovagal balance during the first 5 minutes of surgery was associated with significantly reduced major surgical complications (adjusted odds ratio [AOR], 0.63; 95% CI, 0.41-0.98; P = .04), though not with reduced intensive care unit stay (AOR, 0.34; 95% CI, 0.11-1.01; P = .05) or mortality (AOR, 0.18; 95% CI, 0.03-1.03; P = .05).
Conclusions and Relevance Increased surgeon stress at the beginning of a procedure was associated with improved clinical patient outcomes. The results are illustrative of the complex relationship between physiological stress and performance, identify a novel association between measurable surgeon human factors and patient outcomes, and may highlight opportunities to improve patient care.
