Performance Anxiety in Surgery: Creating Your Psychological Zone of Safety

Performance anxiety in surgery is not uncommon. The high stakes, intense environment, and expectations for perfection can trigger feelings of anxiety and self-doubt. Whether it's fear of making a mistake, concerns about judgment from peers and mentors, or the pressure to meet surgical standards, these factors can weigh heavily on surgeons.

Performance anxiety (PA) is anxiety in reaction to a perceived threat concerning the performance of a task under pressure. It is a well-documented phenomenon among performers and athletes. But anyone who has to perform any task can experience it. Performance anxiety can have a significant impact on surgical performance, by impairing concentration, decision-making, and fine motor skills, ultimately affecting patient outcomes. Moreover, unchecked anxiety can lead to burnout and disillusionment with the surgical profession.

Having some anxiety is healthy. This allows you to be alert, be safe, and be proactive rather than reactive in surgery. Too much complacency when you are dealing with the health and lives of the patient is never a good thing. Too much anxiety, on the other hand,  can paralyze you, make you double-check, and triple-check every move, and create brain fog that you cannot think clearly. It is somewhere in the middle of high and low anxiety that is where you perform your best, which we call the “bliss point of anxiety.” So how do we access that?

I spoke to many experienced surgeons to find out how they manage it. The most common answer is, “It just comes with experience, you just need to do more. However, I have seen ten-year-plus experienced consultants who are super stressed in theatre and a nightmare to work with. While some year one consultants are super calm in theatre and manage whatever comes logically and systematically. Why is that? So, the impact of time and experience may be irreplaceable but not the only antidote to PA.

It is not just the outcome of the operation; it is also your reputation that suffers a hit. If you are perceived as anxious, even if it is justified, you are perceived as not confident. So, a lot of the time, we cannot show our anxiety, which can compound the overall feeling of anxiousness because we do not feel it is safe to do so. My personal belief is being and feeling anxious is VERY normal. What is not normal is to let that paralyze us from acting. What we need to work on is to develop that area of psychological safety within ourselves, where we can acknowledge it, and address the cause of it, while being calm about it.

So how to develop the zone of psychological safety? First, identify which factor makes you anxious. It might be one of these or all of these:

1. Fear of Complication: When you are doing your first gallbladder, you will be worried about injuring the bile duct. So, initially, you will check with your trainer that you are safe. Then, you will develop a mental checklist like developing a critical view of safety that you are indeed safe. But even then, you will suffer complications. The more you do, the more complications you will have. Anyone who says otherwise is either not truthful or never followed up with their patients. But if you follow your safety checklist and know that you have done everything properly and safely, then it is easier to accept and learn from that, to move on.

2. Fear of judgment: Most surgeons are happy to be called for help.  But I have also worked with a fair share of trainers who express their displeasure when being called in the middle of the night or give you a judgmental look or feedback that makes you feel incompetent. There is also the theatre team, your scrub nurse, and an anaesthetist. Everyone who does not do the surgery has an opinion on how to do the surgery. This does impact your performance, especially in your early years, whether as a registrar or consultant. But at the end of the day, patient safety takes priority. Once you are clear on your priority,  you need to that whatever it takes to ensure that.

3. Fear of not knowing: You are at a point in surgery where you have done everything that you can think of but not making progress. Or you do not know what the next step is. Or you are going to do an operation, but you are rehearsing the steps in your mind, like the anatomy of a femoral hernia in the middle of the night. There are several things you can do to mitigate that.

 Pre-operatively, take a bit of time to revise the anatomy. Make a playlist of helpful YouTube videos and keep a diary of the procedure.

 Intra-operatively, when you are in a situation, you can think out aloud, and ask to start a clock, that is if you do not make progress in a set amount of time you will call for help.

Do not hesitate to ask for a second opinion from a colleague or consultant, in person or over the phone. Then follow that patient up and reflect on what done was right or not, and you will feel more confident in facing this situation next time.

4. Fear of Losing control: Surgeons are control freaks, and you must be to a certain extent. Communication issues such as an inexperienced team, and equipment failure, such as a stapler misfiring or not having the standard equipment are the most common causes of making us feel like we are not in control.

The thing to understand is the only thing within our control is control of ourselves and our actions. So,  define what you cannot control, such as staff and equipment. Then decide actively how you will respond to that.

If I know I have an unhelpful scrub nurse, I pay extra attention to my interaction so that I do not stoop to that level of unprofessionalism and do silent breathing exercises to exercise being calm.

 Mention in the team brief what it is you want and confirm they have it. If there is an equipment shortage or they are asking you to use equipment that you are not familiar with, either call a colleague to show you how to use it or get the instrument you want from another theatre or the theatre of the cottage hospital. Do not compromise on patient safety. Do not ever feel pressure to use something you are not familiar with just because “so and so “use it, as per the theatre team. Remember, if a complication happens, none of those excuses will be valid.

Now, try actively reflecting on your experience when you felt super anxious and which of these factors were behind it. Then reflect on how you managed it or saw someone who managed it. Then devise a plan based on your reflection about how you will manage it next time you face it.

Reflective learning of that experience is what makes the difference. Reflection on the chain of events, on your response and actions, and learning from that is what gives you the toolkit to manage stress and give you confidence to manage any situation. For what is confidence is belief in yourself and your abilities to manage any situation.