Mindfulness and the surgeon

Introduction

Mindfulness of the surgeon, encompassing a heightened emotional awareness and control can exert a considerable influence on the performance of the surgical team (1). Mindfulness is defined as the cognitive skill of purposefully bringing one’s attention to the present, devoid of distraction and responding to emotions in a thoughtful rather than reactionary way (2,3). Mindfulness is bolstered by three core components: presence, intention and non-judgement, culminating in elevated compassion amongst healthcare professionals towards themselves and their patients (4-6).

The cognitive and emotional demands of surgery, including long hours, severe personal sacrifice and high-stakes time critical decision-making place surgeons at elevated risk for psychological distress. An untrained mind is prone to distractions and negativity, which further accentuate the cognitive and physical demands of surgery (7). Unlikely to reach out due to concerns for their career, surgeons experience high rates of burnout with suicidal ideation at higher rates than the general population (8). Encouraging an accepting rather than avoidance attitude towards disagreeable and unpleasant situations, mindfulness has been shown to diminish emotional exhaustion and disillusionment amongst medical professionals (9). Improving emotional regulation and meta-cognition bolsters the wellbeing of the individual surgeon and the broader surgical team (10).

Attaining mindfulness during surgery have many benefits, including stress reduction, avoidance of distractions, improved motor performance, and enhanced executive function (7). The beneficial effect of meditation training is supported by biological evidence relating to neuroplasticity and inflammation biomarkers. Mindfulness has been shown to reduce the activity of the amygdala and limbic system (the threat detection and emotional centers) and enhance the activity of the logical prefrontal cortex (11-13). In addition, a reduction in systemic inflammation biomarkers and greater immune function have been reported in mindfulness program participants (6,14).

Mindfulness to cultivate emotional balance can be achieved by meditation, breathing consciousness, noting sounds and thoughts, body scan exercises, and yoga (15). Gurland stressed that mindfulness should be separated from other forms of self-care (such as alcohol, holidays, and distracting activities), which aim to circumvent uncomfortable situations (9).

Three domains of doctor well-being have been described: wellness culture promotion, practice efficiency, and resilience (16). Mindfulness-based interventions (MBIs) can improve personal resilience to diminish the risk of burnout. The cognitive skills of interoception, emotional regulation, and meta-cognition are key components of MBIs (17). Many MBIs take their origins from John Kabat-Zinn’s Mindfulness Based Stress Relaxation techniques (6). Resilience has been defined as an adaptive response to unexpected events while supporting optimal focus, engagement, and performance (18). Burnout has been defined as emotional exhaustion, depersonalisation and reduced professional effectiveness (19,20).

Mindfulness requires guidance, mentoring, modelling, and practice. Avoiding recognition of one’s incompetencies and limitations is emotionally easier, but cultivating nonreactivity to negative thoughts and emotions can enhance resilience to overcome stress and improve empathy towards patients (19,21). This review examines conceptual frameworks, existing evidence and the future directions for mindfulness in surgical practice.

Conceptual foundations

The characteristics of mindfulness have been attributed to active observation of mental processes, attentive listening, demonstration of flexibility and peripheral vision, acknowledgment of bias, humility to accept faults, and compassionate action (22). Sibinga and Wu described seven interrelated attitudinal mindfulness qualities: beginner’s mind, trust, non-judgmental, acceptance, non-attachment, non-striving and patience (23). Adoption of mindfulness can increase metacognition to reduce cognitive biases that lead to diagnostic errors. The attitudes and goals of mindfulness for surgeons have been synthesised and summarised under seven interrelated “C” headings in Table 1.

Levels of mindfulness

Epstein proposed six levels of mindfulness starting with denial, imitation, cognitive curiosity, emotional and attitudinal curiosity, insight, and finally presence (22). Kim categorised the levels as attentiveness, acceptance, cognitive distancing, and finally metacognitive mindfulness (15). Ascending the levels involves taking responsibility, being reflective, increasing multifaceted curiosity, understanding, incorporating all the characteristics in the present time, and mental control growth to regulate cognition.

Unique stressors of surgical practice

Effective surgical performance requires simultaneous management of multiple tasks, requiring cognitive flexibility and sustained mental focus (30). Compounding this cognitive load are the frequent emotional challenges of intraoperative uncertainty and coping with patient and family expectations. Emotions such as frustration, anger, fear, and anxiety are commonly elicited by surgical stressors, degrading both individual and team performance (31). Furthermore, the occupational hazards of long working hours lead to high risks of fatigue and burnout. Chronic occupational stress places physician and patient at greater risk of complications (32). Due to the acute nature of surgery, this demographic is especially vulnerable. Extending beyond the individual, operating theatre dynamics involve significant interpersonal and leadership demands (31).

Resilience

Resilience has been defined as a complex adaptive skill to successfully manage unanticipated disturbances while supporting reliable performance (18,33). By cultivating a calm centre and non-judgemental awareness, mindfulness enables surgeons to re-engage with duties after setbacks (to bounce back) and improve resilience. Rather than a bastion of infallibility, resilience is a mode of recovery and adaptation that allows surgeons to overcome inevitable stresses of practice (33). Surgeon-related resilience supports include valuable guidance, calm personality, anticipatory planning, effective communication, and leadership by example. The challenges of daily cumulative stress and significant external events on performance can be influenced by personal attributes (26). Maddus coined the idea of investing in a resilience bank account to help counter the silent burden that surgeons may carry (26). He identified six individual habits that can improve resilience: sleep, exercise, meditation, gratitude, self-compassion, and connection.

Emotional intelligence (EI)

EI has been defined as a multidimensional ability to appropriately harness and apply the emotions of oneself and others (34). Analogous to mindfulness practice, EI involves self and social awareness, as well as self and relationship management. It can be taught and can improve with experience. A systematic review of 37 journal articles revealed that EI was correlated with surgeon well-being but was most often reported by self-assessment, which may have limited validity in individuals with low levels of insight (34).

Measures of mindfulness

The five-facet mindfulness questionnaire is a 39-item self-reported scale that reports mindfulness with regard to observation, description, acting with awareness, non-judgment of inner experience, and non-reactivity to inner experience (35). Mindfulness has been measured by other questionnaires such as the Cognitive and Affective Mindfulness Scale (CAMS) and the Mindfulness Attention and Awareness Scale (MAAS) (14,36,37). The CAMS scale is a 12-item instrument that reports a single score by measuring attention, awareness, presence, and non-judgmental acceptance (38). The MAAS scale is a 15-item inventory that also presents a single score that measures present-moment attentiveness but does not consider the attitude of acceptance (39).

MBIs and benefits

MBIs can include the components of regular meditation, appreciation, and reframing negative thoughts (2). MBIs have been shown to aid resilience (16,40). It can facilitate flow states when immersion in the present results in increased efficiency and effortless execution of tasks (19).

A review of twenty-four articles on MBIs in surgery reported on benefits of increased mindfulness, improved well-being and enhanced surgical performance (including executive function, technical skills, and communication) (40). A systematic review of eight articles investigating the effects of meditation in surgeons reported motor, mental, and physiological improvements (41). Increased surgeon well-being (reduced stress, anxiety, and burnout), improved motor skills and executive cognitive function with use of MBIs has been confirmed by randomised controlled trials (14,36,42-44). Improved surgeon well-being with MBIs has been confirmed with objective psychometric findings, functional magnetic resonance imaging documentation of brain activity, and peripheral inflammatory biomarker studies (14,43,45).

A meta-analysis of four randomised controlled trials and one cohort study found that MBIs reduced stress, improved mindfulness, and reduced burnout, depersonalisation, and emotional exhaustion (46). Other studies not included in the meta-analysis reported similar findings. A prospective multicentre trial of virtual MBIs in twenty-one neurosurgeons reported significant improvements in stress, emotional exhaustion, and psychomotor performance after intervention (47). A randomised controlled trial of 24 orthopaedic surgery residents reported significantly reduced stress, anxiety, emotional exhaustion, and depersonalisation after use of an MBI phone application (48).

Implementation in surgical culture

Overall, stigmatisation of mental health is an important barrier within surgical culture. Value of technical mastery over the soft skills of self-awareness and emotional regulation creates obstacles for implementation of MBIs effectively (49). However, a growing understanding of how mental stability is linked to surgical performance is a significant enabling factor. Integration into existing wellbeing programs further improves the accessibility of MBIs for surgeons. Accessing MBIs such as meditation and breathwork digitally through applications like Headspace is effective for surgical trainees. A cultural shift from absolutism and cold logic towards acknowledging benefits of mindfulness for emotional burnout is hence necessary.

Reflections

Despite a plethora of mindfulness studies involving clinicians in psychology, anaesthesia and internal medicine, most research involving surgeons was simulation-based or qualitative in nature. Of the available surgeon-based studies, sample sizes were small and there was high heterogeneity of mindfulness programs, ranging from simple “noting” exercise and breathwork to multi-week mindfulness courses. Long-term impact of the mindfulness practice both on surgeon mental health outcome and patient outcomes were not analysed. There is a need for multicentre randomised controlled trials with standardised curricula tailored to the unique challenges in surgery. Follow-up on burnout trajectories, complication rates and cognitive performance is necessary to further verify the use of MBIs.

Conclusions

Mindfulness is a transformative yet underutilised tool for surgeon wellbeing. Crucial for fostering resilience and compassion within surgical culture, studies have demonstrated its importance in aiding emotional regulation, technical precision and preventing burnout. It has also been shown to have beneficial effects on personal development and quality of life. Emotional preparedness and control can be learnt and may contribute to better decision-making during unanticipated adverse events during surgery.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Surgical Journal. The article has undergone external peer review.

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-76/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-76/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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