A new stress intervention program aims to help surgeons reduce stress and burnout, which, left unchecked, can affect quality of care and professional lives. Coping techniques are especially useful in the era of the COVID-19 pandemic.
“Surgery is such an incredibly demanding profession, and the stakes are high,” says Jane Lodato, chief of wellness for the department of surgery at Mount Sinai in New York City.
Surgeons have to juggle relationships with families, the surgical team, and colleagues. “The surgeons I know and have worked with are constantly challenged in the way any human being would be challenged if they keep that type of schedule,” Lodato says. “The demands inherent in the job are significant — physically and psychologically. Throw in a complication in the surgery or something going on in the home front, and people get burn out.”
Lodato, building on her leadership experience in the entertainment industry and Silicon Valley, has helped develop techniques for combatting burnout and stress through mindfulness training and a curriculum designed for surgeons.
The program’s co-creator is Michael Marin, MD, surgeon-in-chief of the Mount Sinai Health System in New York City. “The practice of surgery carries with it a significant amount of stress,” Marin notes. “There are portions of our practice, particularly in the operating room, that exert significant stress on our overall lives and experience.”
For instance, patients might bleed excessively or spring an intestinal leak. These are stressful technical issues that need a quick response, and surgeons work with a team of people who may not be fully engaged.
“Without question, on a scale of 1 to 10 in stress, if a surgeon normally is 7, then add the pandemic, and that brings us to 9,” Marin says. “No matter what you do, the pandemic adds to your stress.”
The new stress intervention program works for all members of the surgical staff. “Dr. Marin and I put together the program to address the burnout, bringing in the mindfulness tools that we’ve customized and adapted for surgeons,” Lodato says. “It’s a surgery-specific set of tools that will help them in many situations.”
The stress intervention tools program is comprised of ongoing private, one-on-one sessions and small group meetings, guest speakers, grand rounds presentations, and a class series, called the Surgeon’s Six. The one-on-one sessions involve stress reduction tools, mindfulness exercises, and coaching. There is a minimum of four sessions, initially, and the sessions can continue weekly or every other week, as needed.
The Surgeon’s Six series is a one-hour class held for six consecutive weeks. These interactive classes include support material and mindfulness practices that surgeons can use in their daily lives.
They are designed for anyone in a surgery department. At Mount Sinai, that includes surgeons, residents, the surgical ICU team, the transgender surgery team, administrators, and support staff.
It is important to embed a structure in an organization. This way, leadership can better help staff when they experience stress and need assistance. Receiving assistance from a familiar colleague can carry more weight than when an offer arrives from a stranger. “The ability to embed people means we begin these training sessions and teaching before a crisis occurs,” Marin says. “If a crisis occurs, there is a friendly, knowledgeable face to get us through the crisis and through to the other side.”
The stress intervention can be adjusted to the needs and availability of the site and staff. “Many groups choose to continue to meet monthly or bimonthly after the end of the series for practice, support, and peer-sharing,” Lodato explains. “From what I have witnessed, it can be beneficial to have a group evolve and bond in this way. It becomes an ongoing source of support.”
The curriculum includes basic calming practices, teaching the importance of perspective, recognizing and handling triggers, tuning into one’s body, developing compassion, and handling the emotional side of surgical complications. “The class addresses the emotional side of complications in surgery, which, inevitably, can arise for anyone,” Lodato says.
Each class, which can be taught in-person or via Zoom, includes exercises that attendees can go through. “We talk about challenging situations that we share, and we teach an exercise that may be used in that situation,” Lodato says.
For example, Lodato teaches surgeons how to change their perspective. “If something is upsetting to you, like a challenging relationship in your work ... then we might talk about tuning into what you are thinking and believing in those moments,” she explains. “What do you assume is true? I might lead you in an exercise to think about the situation.”
This is a form of brain training. “You might realize, having gone through this exercise, that your perspective is something that is autopilot for you,” Lodato says. “In these situations, our brains are wired to have reactions that are habitual. Our thoughts and emotions can hijack us.”
It is important to think about what is going on in one’s mind, which thoughts and emotions are surfacing. “We need to pay attention to them in a new way. Rather than being hijacked in an autopilot, reactive sense, we take a step back, take a pause, and make a choice about what we want to think or do going forward,” Lodato says. “If we can train our brain to pay attention to the roads we drive down, we can spare ourselves a lot of grief, anxiety, anger, and suffering, created by mental and emotional habits that we are unaware of.”
These tactics can work with anyone in any profession, but Lodato has customized it for the surgical department. “Administrators have different stressors than surgeons do, and residents or fellows have different stressors than attendings do,” she explains. “The tools that are provided can help any of them, but the way we approach it might be different according to their role.”
Stress intervention programs need a champion to succeed. “You need a leader like Dr. Marin to walk the walk and practice it,” Lodato says. “We set up programs for residents, administrative leadership, and divisional chiefs. When those people took the classes and started working one-on-one, they became advocates and champions themselves.”
When people go through a stress intervention program and become committed to it, they can pave the way for other surgical center staff to do the same.
Exhaustion occurs when professionals ignore their emotions. It also can occur when people go through their day, perhaps reacting strongly or negatively to feelings of frustration or anxiety. People can be whipsawed by their emotions. “They have different thoughts going on, and they carry that forward, not dealing with it. That creates exhaustion,” Lodato explains. “If you sweep something under the carpet or repeat a behavior that doesn’t serve you or takes a toll on you, it doesn’t go away.”
Accepting the things that cause us difficulty and adopting techniques to deal with them are helpful in eliminating stress, fatigue, and burnout. But it takes training.
“We don’t learn these skills sets, especially in our culture, meaning the U.S. culture, where everyone is going 1,000 miles an hour, and nobody slows down,” Lodato says. “I use the analogy of the surface of the ocean. There are crashing waves, weather storms, and tumultuous water. But if one goes deep down into the ocean, it’s actually very still, calm, and quiet.”
For surgeons and staff, their daily experience can mirror the ocean’s surface with circumstances that feel like crashing waves. With some training, they can access a deeper steadiness. “It can bring us to a place where we preserve our energy by becoming self-aware,” Lodato says.
Intervention skills are not guaranteed to end stress and burnout because surgeons and staff cannot predict and defend against every problem that occurs on any given day. “But we do have a choice and power over how we want to react to it,” Lodato says. “The secret is in how we choose to respond, instead of automatically reacting a certain way. This can save us a lot of stress, suffering, and fatigue.”
The goal is to gather more data on the program’s effectiveness to improve it and then share it with other specialties and health systems. “I think it’s critical to have tools to address the stress that’s inherent in surgery,” Lodato says. “Surgeons are trained, impeccably, in how to operate and what to do, but perhaps there’s room for more training in stress intervention tools.”
Anyone might learn skills in self-awareness, how to deal with their emotions, navigate his or her way through stress, and improve their well-being. “Incorporating these tools into curriculum for residents, fellows, administrative leadership, and all teams is a very realistic and proactive way to give people the skills they need to pay attention internally,” Lodato says.