Resident Stress Level during Steps of Cataract Surgery

Abstract

Purpose To investigate intraoperative stress levels using heart rate monitoring during each step of cataract surgery.

Setting Single tertiary hospital.

Design Observational study recording resident heart rate as a measure of acute stress level during cataract surgeries.

Methods Emory ophthalmology postgraduate year (PGY) 3 and PGY-4 residents operating at Grady Memorial Hospital during the time period of the study were eligible to participate. Chest-strapped Bluetooth devices recorded heart rate during the surgeries. The mean, maximum, and minimum heart rates were then analyzed individually for the following steps of surgery: incisions, continuous curvilinear capsulorhexis, hydrodissection, nucleus disassembly, quadrant removal, cortical cleanup, intraocular lens insertion, and closure. Data collection started in April 2017 and ended in February 2018.

Results Out of the 549 surgeries recorded, 427 yielded viable data. Across that dataset, quadrant removal had the highest adjusted mean heart rate value (90.3; 95% confidence interval [CI]: 82.9–97.7; p < 0.0001), highest adjusted maximum heart rate value (97.3; 95% CI: 89.5–105.3; p < 0.0001), and highest adjusted minimum heart rate value (82.1; 95% CI: 75.2–89; p < 0.0001). Nuclear disassembly and incisions were second and third highest, respectively.

Conclusions Quadrant removal, nucleus disassembly, and incisions are the three most stressful steps for resident surgeons. This knowledge should be applied to enhance the resident experience by emphasizing these steps during surgical preparation and training. Future studies using intraoperative heart rate monitoring may be warranted to better understand the resident and attending experience and ultimately improve surgical outcomes.

Keywords

cataract - training - residents - residency - stress - heart rate - steps

Note

This paper was presented at the Association of University Professors of Ophthalmology's Educating the Educators meeting in Austin, Texas, in January 2018.

Conflict of Interest

None.

• References

• 1 Becker WG, Ellis H, Goldsmith R, Kaye AM. Heart rates of surgeons in theatre. Ergonomics 1983; 26 (08) 803-807
• 2 Payne RL, Rick JT. Heart rate as an indicator of stress in surgeons and anaesthetists. J Psychosom Res 1986; 30 (04) 411-420
• 3 Arora S, Tierney T, Sevdalis N. , et al. The Imperial Stress Assessment Tool (ISAT): a feasible, reliable and valid approach to measuring stress in the operating room. World J Surg 2010; 34 (08) 1756-1763
• 4 Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000; 320 (7237) 745-749
• 5 Hammermeister J, Burton D. Stress, appraisal, and coping revisited: examining the antecedents of competitive state anxiety with endurance athletes. Sport Psychol 2001; 15: 66-90
• 6 Driskell JE, Salas E. Overcoming the effects of stress on military performance: human factors, training, and selection strategies. In: Gal R, Mangelsdorff A, eds. Handbook of Military Psychology. Oxford: John Wiley & Sons; 1991:183–193
• 7 Crocker PR, Alderman RB, Smith FM. Cognitive-affective stress management training with high performance youth volleyball players: effects on affect, cognition, and performance. J Sport Exerc Psychol 1988; 10: 448-460
• 8 Hassan I, Weyers P, Maschuw K. , et al. Negative stress-coping strategies among novices in surgery correlate with poor virtual laparoscopic performance. Br J Surg 2006; 93 (12) 1554-1559
• 9 Flin R, O'Connor P, Crichton M. Safety at the Sharp End: A Guide to Non-Technical Skills. Aldershot: Ashgate; 2008
• 10 Klein G. The effects of acute stress on decision making. In: Driskell JE, Salas E, eds. Stress and Human Performance. Mahwah, NJ: Erlbaum; 1996
• 11 Arora S, Sevdalis N, Nestel D, Tierney T, Woloshynowych M, Kneebone R. Managing intraoperative stress: what do surgeons want from a crisis training program?. Am J Surg 2009; 197 (04) 537-543
• 12 Wetzel CM, Kneebone RL, Woloshynowych M. , et al. The effects of stress on surgical performance. Am J Surg 2006; 191 (01) 5-10
• 13 Randleman JB, Wolfe JD, Woodward M, Lynn MJ, Cherwek DH, Srivastava SK. The resident surgeon phacoemulsification learning curve. Arch Ophthalmol 2007; 125 (09) 1215-1219
• 14 Rutar T, Porco TC, Naseri A. Risk factors for intraoperative complications in resident-performed phacoemulsification surgery. Ophthalmology 2009; 116 (03) 431-436
• 15 Quillen DA, Phipps SJ. Visual outcomes and incidence of vitreous loss for residents performing phacoemulsification without prior planned extracapsular cataract extraction experience. Am J Ophthalmol 2003; 135 (05) 732-733
• 16 Prakash G, Jhanji V, Sharma N, Gupta K, Titiyal JS, Vajpayee RB. Assessment of perceived difficulties by residents in performing routine steps in phacoemulsification surgery and in managing complications. Can J Ophthalmol 2009; 44 (03) 284-287
• 17 Review Committee for Ophthalmology. ACGME (2013). Required Minimum Number of Procedures for Graduate Residents in Ophthalmology. Available at: www.acgme.org/Portals/0/PFAssets/ProgramResources/240_Oph_Minimum_Numbers.pdf . Accessed July 14, 2018
• 18 Stephenson M. Advancements in Surgical Microscopes. Review of Ophthalmology [Published May 5, 2015]. Available at: https://www.reviewofophthalmology.com/article/advancements-in-surgical-microscopes . Accessed July 20, 2018
• 19 LeBlanc V, Woodrow SI, Sidhu R, Dubrowski A. Examination stress leads to improvements on fundamental technical skills for surgery. Am J Surg 2008; 196 (01) 114-119
• 20 Chajut E, Algom D. Selective attention improves under stress: implications for theories of social cognition. J Pers Soc Psychol 2003; 85 (02) 231-248
• 21 de Geus EJ, van Doornen LJ, de Visser DC, Orlebeke JF. Existing and training induced differences in aerobic fitness: their relationship to physiological response patterns during different types of stress. Psychophysiology 1990; 27 (04) 457-478
• 22 Boutcher SH, Stocker D. Cardiovascular response of young and older males to mental challenge. J Gerontol B Psychol Sci Soc Sci 1996; 51 (05) 261-267
• 23 Uchino BN, Birmingham W, Berg CA. Are older adults less or more physiologically reactive? A meta-analysis of age-related differences in cardiovascular reactivity to laboratory tasks. J Gerontol B Psychol Sci Soc Sci 2010; 65B [phone]
• 24 Huang CJ, Webb HE, Zourdos MC, Acevedo EO. Cardiovascular reactivity, stress, and physical activity. Front Physiol 2013; 4: 314
• 25 Lee JS, Hou CH, Yang ML, Kuo JZ, Lin KK. A different approach to assess resident phacoemulsification learning curve: analysis of both completion and complication rates. Eye (Lond) 2009; 23 (03) 683-687
• 26 Puri S, Kiely AE, Wang J, Woodfield AS, Ramanathan S, Sikder S. Comparing resident cataract surgery outcomes under novice versus experienced attending supervision. Clin Ophthalmol 2015; 9: 1675-1681