Invited Commentary
January 15, 2025
Turning Stress Into Success—Surgery as Professional Sport
Steven Yule, Jennifer Yule, Calum Arthur
JAMA Surg. Published online January 15, 2025. doi:10.1001/jamasurg.2024.6041
In the latest issue of JAMA Surgery, Awtry et al1 report that elevated surgeon stress, measured by heart rate variability (HRV) within the first 5 minutes of operating, is inversely associated with surgical complications. These findings challenge the traditional view of stress as harmful in high-demand roles, mirroring decades of sports psychology research showing that moderate stress enhances performance.
Elite athletes are characterized by focused, successful performance under pressure.2 They are coached to turn acute stress into enhanced decision-making and goal-directed behavior. For example, the US Tennis Association develops players’ technical, tactical, physical, and mental skills with data-driven analytics captured during training sessions and match play. Adapted to surgical settings, these insights could enhance team performance and outcomes.
We congratulate Awtry et al1 for successfully negotiating the technical, ethical, and human factor challenges of measuring real-time stress responses across multiple sites. Restricting surgeon HRV recording to the start of each operation maximized feasibility of measurement. Future studies could track physiological responses throughout surgical procedures to understand stress variations over time.3 Segmenting HRV measurements by phase of operation would also enable testing nonlinear models, such as the Yerkes-Dodson law,4 where moderate stress is beneficial to outcomes, but performance declines at higher levels.
Although HRV serves as a stress proxy in the present study, it often reflects cognitive load in the surgical literature.5The observed HRV spikes may indicate heightened anticipation rather than distress caused by task demands, recently observed among international rugby medics immediately before kickoff.6 Distinguishing cognitive load from stress would clarify HRV’s preparatory role, strengthening its physiological basis as a biomarker of cognitive engagement.
Surgery is a team effort, and affective states, including stress, can be contagious in groups.7 After repeated tournament losses in the 1990s, the England soccer team started practicing penalties while fatigued and using breathing exercises to manage stress. In Euro 2024, Arsenal’s Bukayo Saka drew on performance psychology training to confidently score a crucial penalty against Switzerland.8 Monitoring HRV of the entire surgical team could provide insights into contagion of surgical stress, including impact on trainees. Patients also recognize surgeons’ nontechnical skills, such as handling pressure.9 While the media often shows surgeons heroically facing life-or-death situations, patient trust can be maintained by presenting operative stress as normal and beneficial.
Ultimately, the personal experience of stress, rather than its intensity, shapes the relationship between anxiety and performance. Surgeons can adopt athletes’ strategies by reframing stress constructively (eg, “I am nervous but confident”), practicing mental imagery, and tracking cognitive load using wearable sensors. Applying these performance-enhancing techniques from professional sports to operating rooms has the potential to unlock unprecedented gains in outcomes and foster a resilient surgical culture.
