Association Between Surgeon Stress and Major Surgical Complications
Authors: Awtry Jake , Skinner Sarah , Polazzi Stephanie , Lifante Jean-Christophe , Dey Tanujit , Duclos Antoine ,   TopSurgeons Study Group, Badet Lionel , Bates David W. , Bonin-Crepet Lucie , Cannarella Olivier , Carnicelli Damien , Carrerre Martin , Charlot Keyne , Chaudier Phillipe , Chene Gautier , Chollet Francois , Cloud Virginie , Cordier Quentin , Cormont Ethan , Cortet Marion , Cotte Eddy , Crouzet Sebastien , Dagnino Fillipo , de la Cruz Kim I. , Fassier Jean-Baptiste , Francois Yves , Gertych Witold , Golfier Francois , Gorioux Romain , Goutard Claire-Angeline , Gunst Stanislas , Hermine Muriel , Hoen Nathalie , Kepenekian Vahan , Lamblin Gary , Lesurtel Mickael , Louboutin Lucie , Lustig Sebastien , Mabrut Jean-Yves , Maillard Laure , Maury Jean-Michel , Mazza Stephanie , Mohkam Kayvan , Morel-Journel Nicolas , Nohuz Erdogan , Nunes Andrea , Obadia Jean-Francois , Pascal Lea , Pasquer Arnaud , Passot Guillaume , Pelascini Elise , Philip Charles-Andre , Pibarot Vincent , Poncet Gilles , Pozzi Matteo , Prieur Hugo , Robert Maud , Rongieras Frederic , Ruffion Alain , Schlatter Sophie , Sebaoui Sofia , Servien Elvire , Soelling Stefanie , Stelzl Daniel , Trinh Quoc-Dien , Tronc Francois , Vaudoyer Delphine , Villeneuve Laurent , Viste Anthony , Vola Marco , Warembourg Sophie , Weissman Joel S 
Published: January 2025

Importance

Surgeon stress can influence technical and nontechnical skills, but the consequences for patient outcomes remain unknown.

Objective

To investigate whether surgeon physiological stress, as assessed by sympathovagal balance, is associated with postoperative complications.

Design, Setting, and Participants

This multicenter prospective cohort study included 14 surgical departments involving 7 specialties within 4 university hospitals in Lyon, France. Exclusion criteria consisted of patient age younger than 18 years, palliative surgery, incomplete operative time-stamping data, procedures with a duration of less than 20 minutes, and invalid surgeon heart rate variability (HRV) data. Data were accrued between November 1, 2020, and December 31, 2021, with 30-day follow-up completed on May 8, 2022. Analyses were performed from January 1 to May 31, 2024.

Exposure

Sympathovagal balance of the attending surgeon in the first 5 minutes of surgery.

Main Outcomes and Measures

Major surgical complications, extended intensive care unit stay, and mortality within 30 days, after adjustment via mixed-effects multivariable logistic regression for surgeon age, professional status, the time of incision, the random effect of the surgeon, and a composite risk score incorporating patient comorbidities and surgery characteristics. Sympathovagal balance was quantified by the low frequency to high frequency (LF:HF) ratio derived from HRV data measured by chest monitors worn intraoperatively. The LF:HF ratio was normalized at the surgeon level to the median value observed for each surgeon during the study period to control for baseline differences.

Results

A total of 793 surgical procedures performed by 38 attending surgeons were included in the analysis. Median patient age was 62 (IQR, 47-72) years, and 412 (52.0%) were female, with a median of 2 (IQR, 1-4) comorbidities. Median surgeon age was 46 (IQR, 39-52) years, 39 (78.9%) were male, and 22 (57.9%) were professors. Median surgeon heart rate was 88 (IQR, 77-99) beats per minute. Median surgeon LF:HF ratio was 7.16 (IQR, 4.52-10.72) before and 1.00 (IQR, 0.71-1.32) after normalization. Increased surgeon sympathovagal balance during the first 5 minutes of surgery was associated with significantly reduced major surgical complications (adjusted odds ratio [AOR], 0.63; 95% CI, 0.41-0.98; P = .04), though not with reduced intensive care unit stay (AOR, 0.34; 95% CI, 0.11-1.01; P = .05) or mortality (AOR, 0.18; 95% CI, 0.03-1.03; P = .05).

Conclusions and Relevance

Increased surgeon stress at the beginning of a procedure was associated with improved clinical patient outcomes. The results are illustrative of the complex relationship between physiological stress and performance, identify a novel association between measurable surgeon human factors and patient outcomes, and may highlight opportunities to improve patient care.