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.
Commentaire du Dr Marius Laurent (PAQS)
- De cette étude qui a pris place dans des hôpitaux de Lyon, seul le premier auteur est américain, les autres sont français. La question posée est de savoir dans quel sens un niveau de stress évalué au début d’une intervention chez des chirurgiens expérimentés peut influencer le pronostic du patient. Le niveau de stress est mesuré par des paramètres de la variabilité du rythme cardiaque, mesuré battement par battement, en l’occurrence par le rapport entre la fréquence la plus basse et la plus élevée (LF/HF). Ce rapport évolue parallèlement à la balance entre le tonus vagal et le tonus orthosympathique, et puisque la mesure est effectuée en dehors de périodes d’activité physique, elle est censée mesurer un stress cognitif plutôt que physique. La mesure est normalisée pour chaque chirurgien en la comparant à la médiane des mesures effectuées pendant toute la durée de l’étude chez ce chirurgien (au total, 793 interventions chez 38 chirurgiens). Ce qui est remarquable, c’est qu’un niveau de stress élevé en début d’intervention est corrélé avec moins de complications opératoires (mais pas avec la mortalité ou la probabilité d’un séjour aux soins intensifs). Chez ces chirurgiens confirmés, un certain niveau de stress en début d’intervention garantit apparemment un meilleur résultat : on peut supposer davantage d’attention, une plus grande concentration au bénéfice du patient. Ce résultat peut paraître contre-intuitif dans la mesure où le stress est souvent associé, dans nos esprits, à une dégradation de nos performances techniques et non techniques. Ce n’est pas le cas dans cet échantillon de chirurgiens expérimentés n’effectuant pas d’intervention à haut risque (90% de chirurgie élective). Les auteurs posent la question (intellectuelle…) de savoir si des techniques de biofeedback susceptibles de modifier le rapport LF/HF auraient aussi une influence sur le devenir du patient ?
Awtry J, Skinner S, Polazzi S, et al. Association between surgeon stress and major surgical complications. JAMA Surg. 2025;160(3):332–340. Doi : 10.1001/jamasurg.2024.6072