Stress
Stress
Stress
ScienceDirect
Article history: Mental skills and emotional regulation training are gaining acceptance in surgical educa-
Received 21 August 2020 tion as vital elements of surgeon development. These skills can effectively enhance
Received in revised form technical skill development, improve well-being, and promote career longevity. There is
6 January 2021 evidence emerging in the surgical education literature to support the incorporation of
Accepted 15 January 2021 mental skills and emotional regulation training curricula in residency training. In this
Available online 5 March 2021 study, we present the existing evidence supporting the use of this training with high
performers to reduce stress and optimize well-being and performance. We also consider
Keywords: the recent research emerging in surgical education that offers validity evidence for use of
Mental skills mental skills training with surgeons. Finally, we provide a framework to guide the incor-
Emotional regulation poration of these skills throughout the career of a surgeon and suggest methods to promote
Resilience the development of mental skills training efforts nationally.
Stress ª 2021 Elsevier Inc. All rights reserved.
Performance
Mindfulness
This invited white paper was written in conjunction with a Hot Topics symposium presented at the 15th annual meeting of the Ac-
ademic Surgical Congress in Orlando, FL on June 02, 2020.
* Corresponding author. Surgical Skills Coach, Department of Surgery, Indiana University School of Medicine, 702 Rotary Circle, R022b,
Indianapolis, IN 46202. Tel.: 317-274-3164; fax: 317-274-8769.
E-mail address: nanton@iu.edu (N.E. Anton).
0022-4804/$ e see front matter ª 2021 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jss.2021.01.009
A2 j o u r n a l o f s u r g i c a l r e s e a r c h j u l y 2 0 2 1 ( 2 6 3 ) a 1 ea 1 2
substantial extant evidence supporting the value of MST, and interactions with the environment and assess their relevance
orient surgeons to become leaders in promoting and to well-being (i.e., potentially harmful versus beneficial). Sub-
resourcing these efforts locally and nationally. sequent appraisal determines if adequate abilities and re-
sources exist to avoid harm, and this calculus determines an
individual’s perceived ability to cope. If a situation is
What is stress? appraised as threatening (or simply provocative), stress is
heightened and a cascade of sympathetic nervous system
As surgeons we know the experience of stress well: the rapid (SNS) activation is initiated. The body is mobilized to
heart rate and adrenaline rush of myriad things to do. Yet, respond,18,19 resulting in what we know as the ‘fight or flight’
while familiar, stress remains hard to define. In the modern response.20 Evolutionarily, this reaction is essential to survival
conceptualization, stress is a comprehensive term that re- and in the short term can stimulate adaptation and mastery of
flects increased arousal in response to both positive and new skills. In accordance with the ‘broaden and build’ para-
negative stimuli. Reflecting its heterogeneous and dynamic digm,21 this experience of stress increases an individual’s
nature, stress can be stimulating or toxic and can be caused by sense of capability, enhances their perceived ability to cope,
different things for different people on different days.4,5 In and increases their likelihood of facing future adversity in a
spite of its variable etiology, the initial effect of stress is uni- similarly masterful fashion.22 A key component of ‘broaden
versal and evolutionary: we physically prepare to fight or flee, and build’ recognizes that one’s perception of having
we are compelled by a desire to react, and what we do next is adequate abilities is based on both past performance and
mediated by feedback between the hypothalamic-pituitary- one’s sense of self. This latter point is the domain of mental
adrenal axis and the prefrontal cortex.6 This last point is training and emotional regulation, whereby ability can be
critical because it underscores the reciprocal communication dramatically influenced by positive versus negative self-talk,
that governs the human stress response and clarifies how our mental imagery of success versus failure, and a growth
experience of stress is related to cognition. As such, there is versus a fixed mindset.13,23,24 These principles are founda-
growing awareness that stress can be mediated by cognitive tional to high-performance sports psychology12,24 and sup-
skills, as first evidenced by studies of resilient individuals.7-9 ported by studies in elite women athletes,13 military “soldier
Resilient individuals, often concentrated in high-stress, athletes”,25 and meta-analysis across sports fields.26
high-performance fields, share a common cognitive ten- On the contrary, if stressors are prolonged or over-
dency to perceive stressors as surmountable rather than whelming, an individual’s sense of capability can become
overwhelming events.10 This kind of mental shift is familiar to overtaxed and they can be pushed to the “threat” side of the
surgeons and is exemplified in the scenario of uncontrolled “inverted-U” curve. This decline can be promoted or exacer-
operative bleeding. As medical students, our natural reaction bated by individual factors, such as poor self-perception,27
to a pumping artery is to flinch or freeze, but somewhere in habituated negative self-talk,13 or simply a lack of coping
the process of training, we learn to subvert this reaction and skills.28 Systems’ factors in the form of external resources play
replace it with controlled calm. This represents an adaptive an equally critical role, as evidenced by the deleterious effect
response (a cognitive shift) that can be learned. With rein- of poor social support in studies of job strain and workplace
forcement and practice, such skills can be called on more satisfaction.29 An increasing body of evidence underscores the
readily and as needed. impact of chronic psychosocial stress and describes the
adverse physiologic, cognitive, and affective impact of this
“allostatic load”, particularly when it is prolonged.30-32
Stress and performance
Cultivating the ability to reframe stress has profound impli- Stress and well-being
cations for performance. Decades of empirical work in both
basic science and with top-performing athletes highlights The field of social genomics provides insight into the mecha-
how stress in the right circumstances can stimulate adapta- nism by which chronic or overwhelming stress drives physi-
tion and mastery.11-14 These observations exemplify the ologic deterioration by identifying specific types of human
Yerkes-Dodson law, often referred to as the “inverted-U phe- gene activation patterns associated with adverse social con-
nomenon”, which proposes that increasing stress is beneficial ditions.31,33 The “conserved transcriptional response to
to achieve optimal performance,15 but that beyond this point, adversity”,34 characterized by increased activity of proin-
additional stress results in decline. In an attempt to clarify this flammatory gene transcription pathways (i.e., NFkB and AP-1)
further, Selye (1987) differentiated distress (i.e., that which and decreased activity of the innate antiviral response (e.g.,
negatively affects an individual’s state) from eustress (i.e., type I interferons), is a common pattern of gene transcrip-
that which positively affects an individual’s state), noting that tional alterations that occur with chronic low-grade SNS
these states are largely dependent on an individual’s inter- stimulation such as that found in populations experiencing
pretation and reaction to the stimuli at hand.16 A key question socioeconomic stress, social isolation, or sleep deprivation.30
is what determines this critical interpretation and reaction? This state has been linked to the development of cardiovas-
Indeed, Folkman et al. (1986) describe two primary pro- cular disease,35 Alzheimer’s dementia, and cancer.36,37
cesses, cognitive appraisal and coping, which mediate the Cognitively, profound or chronic SNS activation can
individual-environment stress relationship.17 Cognitive decrease working memory capacity (i.e., the system respon-
appraisal is a process whereby individuals evaluate sible for temporary storage and manipulation of information),
anton et al mastering stress A3
regarding both the need for and efficacy of MST for surgeons nonsurgical trainees and practicing surgeons. Early studies of
confirms the feasibility and value of adopting an ‘internal ESRT among surgery trainees demonstrated feasibility and
surgical curriculum’ to augment traditional intellectual and acceptability as evidenced by the reasonable implementation
technical training.1-3,66,67 cost, low attrition, and high rate of home practice. Further-
more, ESRT was perceived as credible and satisfying, in spite
of the untraditional content and the need for in-person class
Mental skills interventions in surgery and attendance. Skills were readily integrated into participants’
evidence of effectiveness everyday lives.68 Early studies also showed ESRT participants
to have reduced stress, increased working memory capacity,
There have been substantial efforts made to develop mental increased activation of neural substrates associated with ex-
skills and emotional regulation training programs with sur- ecutive cognitive function, emotional regulation, and complex
geons. Because our groups (Departments of Surgery at Uni- bimanual coordination,72 and better performance on laparo-
versity of California, San Francisco (UCSF) and Indiana scopic simulator tasks. More recent work has demonstrated
University (IU)) have published a significant amount of statistically significant benefits to ESRT participants in terms
research on the efficacy of our programs, we will highlight of lower emotional exhaustion, lower depersonalization,
these programs first. We will then briefly highlight other higher mindfulness, and higher global executive cognitive
programs designed to implement mental skills and emotional function both postintervention and at long-term follow-up.
regulation skills in surgery. Moreover, ESRT participants showed statistically significant
At UCSF, our group has developed enhanced stress resil- mitigation of a stress-activated proinflammatory gene
ience training (ESRT) which is a streamlined and tailored MBI expression profile (conserved transcriptional response to
loosely based on John Kabat-Zinn’s mindfulness-based stress adversity), as compared with controls.2 With the onset of the
reduction, the most scientifically vetted MBI to date.68 The COVID-19 pandemic, ESRT was modified for remote delivery
core components of ESRT focus on the development of three and was successfully provided to practicing surgeons at 10
key cognitive skills: interoception (i.e., moment-to-moment academic sites, across all four US time zones, and to individ-
situational awareness of thoughts, emotions, and sensa- ual surgeons in the military. In 2020, for the first time, ESRT is
tions),69 emotional regulation (i.e., development of non- part of the mandatory educational curriculum for incoming
reactivity in response to internal and external stimuli),70 and UCSF residents in surgery and obstetrics and gynecology.
metacognition (i.e., conscious awareness of one’s cognitive At IU, a novel mental skills curriculum (MSC) designed to
control processes).71 These skills are taught through experi- reduce stress and enhance the performance of surgery resi-
ential training in various mindfulness practices (focused dents has been developed and implemented. This MSC con-
breathing, body scan, qi gong) and scaffolded onto a concep- sists of eight modules (outlined in Table 2) and was developed
tual framework explaining their relationship to cognitive by a multidisciplinary team of a surgeon educator, a PhD
training, emotional regulation, and behavior change for the educator with industrial design expertise, and a performance
purpose of enhancing stress resilience in physicians. Criti- psychologist with expertise in MST.73 The modules are
cally, there is an emphasis on bringing these skills into sur- implemented with residents in weekly sessions and feature
geons’ daily lives through informal (i.e., ‘‘throughout the day’’) video education and didactics with a trained mental skills
practice and explicit contextualization of skills to the personal coach, workbook exercises for immediate practice of learned
and professional circumstances of surgeons.2 skills, and applied practice of surgical skills during simulation
For example, using emotion regulation techniques in training. We have accumulated evidence of effectiveness for
difficult communication with other health care workers, this curriculum through the conduct of numerous studies. We
mindful walking during rounds, breathing techniques to have shown that novices significantly improved their laparo-
dispel stress and reclaim attention in the operating room (OR), scopic surgical skills and mental skills use73 and experienced
and using metacognitive skills to transition out of work and significantly lower stress during two validated stress tests
enjoy personal time more fully. The goal of this applied after training with this curriculum.74 We have also shown that
practice is to explicitly mitigate the most common and this curriculum enhances skill transfer from the simulated
recurring sources of surgeons’ stress and emphasize the environment to the clinical environment75 by minimizing the
pragmatic importance of integrating mindfulness practices typical skill deterioration that is observed during this transi-
within daily life. The course comprises five 1-h classes with a tion.76 In a randomized-controlled trial with surgical novices,
focus on experiential practice, not intellectual content we found that MSC-trained novices demonstrated higher
(Table 1). A progressive amount of daily home practice is laparoscopic skill retention 2 months after training compared
assigned, and a voluntary group meditative hike (2-3 h out- with controls.77 Importantly, our group implemented our MSC
doors) is held after week 3 or 4. The ESRT curriculum bundle with surgery residents in a multisite, randomized-controlled
involves an online platform of short videos which deliver the trial of its effectiveness.1 After stratification of residents into
conceptual framework, an app-based platform of guided training conditions (i.e., MSC and controls), both groups were
meditation recordings to support daily home practice, and a trained in laparoscopic skills and asked to participate in a
facilitators’ guide (detailed manual) to support transfer test on a porcine Nissen model. Residents were asked
implementation. to perform under normal and stressful conditions where
Since its inception, in 2016, ESRT has been studied in two stressors (e.g., interruptions, technical challenges, poor
single-institution randomized controlled trials, of a total of 65 assistance, etc.) were introduced by the study team. We found
first-year surgery trainees, and several cohort studies of that in spite of both groups performing comparably under
anton et al mastering stress A5
Table 1 e Practical and conceptual differences: traditional MBSR, ESRT-beta, and final ESRT.
Modification Traditional MBSR ESRT-beta Purpose of Final ESRT Purpose of
modification modification
Practical
Class number 9 wk 6wk (L) to utilize 6-wk 5 wk (C) further
Intro session þ 8 wks summer gap in didactics minimize clinical
disruption
Class duration 2.5 h 1.5 h (L) provide protected 1h (L, C) to enhance
Emergent, Focused time, while preserving Explicit, short video- acceptability and
metaphorical, discussions 80h work-week, based conceptual accessibility
breaks, didactics and didactics, educational and OR time content
no break
Retreat 8h silent sitting 3h ‘Medi Hike’, (C) request for fresh air No change
retreat, off-site outdoors and exercise
meditation center
Assigned daily 45 min daily 20 min daily (C) responsive to time- Goal is consistency, (C) ‘failing’ at
practice time compressed surgical ideal is 20 min, 20 min, added to
lifestyle emphasis on informal participant stress
(“all day long”) practice (Type A personality)
Conceptual
Class content 1.5 hdmeditation 1hdmeditation (L) preserve experiential 45-50 mindmeditation (C) capitalize on
1hdsharing, stories, 30 mindless focus, shorten class time 10-15 mindexplicit culture of skills
Meandering sharing, more concepts training, fast
approach focused learners
approach
Emphasis Insight, life-long Skill set for (C) application to life, Resilience skill set, (C) growing
learning about self, stress relationships, training, specific work distress and
world. Broad health resilience, in career longevity application, cognitive burnout,
enhancement. general training. modeling ESRT in
work, life.
Contextualization Broad application of Application to (C) skills applied to Emphasize applied (C) explicit skills
concepts, awareness personal and surgeons’ life and work techniques, all day, for explicit
to all interactions professional various scenarios situations, clear
situations mental model
Expectation Committed formal Daily practice (C) reinforce ‘some is Train formally, but ‘live (C) capitalize on
practice mostly formal, better than none at all’ your practice’. Informal natural tendency
less informal practice, anywhere, all for repetition and
day ritual
(L) ¼ logistical modification; (C) ¼ cultural modification; MBSR ¼ mindfulness-based stress reduction; ESRT-beta ¼ enhanced stress resilience
training early version, 6 wk, 1.5-h classes, 20 min/d home practice; ESRT-Final ¼ enhanced stress resilience training final postiterative version, 5
wk, 60-min classes, progressive amount of daily formal practice, heavily emphasized informal practice.
normal conditions, MSC-trained residents were able to pre- enhancing skill acquisition and surgical performance,
serve their surgical skill significantly better than controls increasing confidence, knowledge, teamwork, and reducing
under stressful conditions. stress. There have also been efforts in surgical education to
Thus, our studies demonstrate that the IU MSC is effective implement stress-resilience training to improve surgeon
in increasing mental skills of participants, enhancing their well-being. Riall et al. (2017) have developed the “Energy
surgical skill acquisition and retention, and minimizing per- Leadership Well-Being and Resiliency Program” for surgeons,
formance deterioration under stressful conditions in the OR. which is a curriculum designed to address the mental, social,
Given these findings, this curriculum has been incorporated and physical elements of surgery residents’ well-being.3
into our surgery residency curriculum to benefit all our During monthly sessions, residents are taught skills related
trainees. to goal setting, mindfulness, team building, communication,
There have been efforts beyond our groups to implement work-life balance, empathy, diet and exercise strategies,
mindfulness-based stress reduction and mental skills in- mindfulness of ergonomics, and stress management tech-
terventions in surgical education that warrant mention as niques. The authors found that their program improved
well. In a recent review of mental skills interventions in residents’ exhaustion, life satisfaction, perceived stress,
surgery, we found that before 2017, 19 studies had been emotional intelligence, and overall perception of the resi-
conducted to assess the benefit of mental skills (i.e., primarily dency program. Residents reported that they were able to
mental imagery) for surgical novices and trainees.78 Results incorporate these skills into their daily work and personal
indicate that these interventions are highly effective for lives, which provides further evidence that regular practice of
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Table 2 e (continued )
# Module Description Goals and objectives
7 Preoperative Techniques and principles to ensure that one is The goal of this session will be to equip the learner with
mental routines mentally ready to perform, as well as physically and the knowledge and skills to develop preperformance
technically ready; includes preparation for both the mental routines. By participating in this session, the
initiation of a procedure and resuming after a break or learner will.
loss of focus develop a clear preperformance “mental readiness”
routine for OR performance
mindfulness and mental skills provides beneficial down- deterred by the time required to learn these skills. Trainees
stream effects. perceive these programs as valuable to their performance and
well-being,68,73 when they are framed as skills with evidence-
based roots. The question becomes, how can leaders imple-
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