Surgeon reported measures of stress and anxiety prior to and after elective gynecological surgery

Abstract

Introduction

Performing surgical procedures is a recognized source of stress for surgeons. Vocational stress is an important contributor to performance, patient care, and burnout with dispositional and environmental factors contributing. Accurately assessing surgeon stress is critical to measuring effectiveness of stress reduction programs. The primary aim was to identify differences between surgeons' self‐reported anticipated stress and anxiety prior to gynecological surgery, compared with their recollection of experienced stress and anxiety during surgery. Secondary aims assessed any differences by level of training, surgical type, and surgeon role.

Material and methods

Attending and resident gynecologists performing routine elective surgeries completed a visual analog scale (VAS) assessing perceived stress and the State–Trait Anxiety Inventory (STAI) prior to and immediately after completing 161 elective surgeries including total laparoscopic hysterectomy, laparoscopic excision of moderate–severe endometriosis, or hysteroscopic myomectomy.

Results

Eight attending gynecologists and nine residents participated. Residents commenced as primary surgeon in 62/90 (69%) procedures. Stress experienced during surgery was greater than anticipated in 92/161 (57%) surgery episodes (mean VAS increase: 3.9; 95% CI: 1.1–6.8, p = 0.009). State anxiety was greater than anticipated in 99/161 (62%) episodes (mean state anxiety increase: 4.4; 95% CI: 3.0–5.8, p < 0.001). Greater preprocedural anticipatory stress and anxiety was observed in residents vs. attending gynecologists (VAS 51.9 vs. 22.8, p < 0.001; state anxiety 38.3 vs. 28.1, p < 0.001) and in primary vs. assistant surgeons (VAS 47.2 vs. 29.9, p < 0.001; state anxiety 36.9 vs. 28.3, p < 0.001). Intraoperative stress and anxiety were greater in primary surgeons (VAS 50.4 vs. 30.5, p < 0.001; anxiety 41.3 vs. 32.5, p < 0.001) and residents (VAS 43.4 vs. 31.7, p < 0.001; anxiety 53.5 vs. 33.7, p < 0.001) compared with assistants and attending gynecologists. Perceived stress and anxiety were positively correlated at both timepoints (r = 0.68, p < 0.001; r = 0.82, p < 0.001).

Conclusions

When asked to reflect on stress experienced during surgery, our data show that stress during surgery is greater than anticipated for many surgical episodes. Self‐reported stress symptoms commence prior to surgery and are more commonly reported by surgeons operating as primary surgeon and by those in training. Future research should focus on determinants of presurgical stress and examine when stressors become inhibitory to performance.

Surgeons were assessed for stress and anxiety over three common gynecological procedures. Stress was higher in residents and primary surgeons. Anxiety increased in the majority of surgery.

Abbreviations

PROM

participant reported outcome measure

STAI

state trait anxiety inventory

VAS

visual analog scale

Key message.

Self‐reported stress and anxiety during surgery was greater than anticipated stress before surgery. Higher anticipated stress was associated with being primary operator and less experience. Differences between anticipated and recollected stress were not influenced by operator or level of training.

1. INTRODUCTION

A surgical career is both physically and psychologically demanding with increasing reports of high rates of burnout in surgeons. ¹ In addition to long and unsociable working hours, surgeons are required to develop a firm of understanding of disease, anatomy, surgical techniques, and scientific evidence, and must master multiple intraoperative skills including psychomotor (visuospatial skills, dexterity, hand‐to‐eye coordination), interpersonal (teamwork, communication, leadership), and advanced cognitive skills (surgical planning and error prevention, error recognition, rescue and recovery). ² These demands on surgeons as well as the requirement to master new and increasingly difficult surgical procedures and to maintain attention to intricate technical details for sustained periods of time can contribute to excessive stress. While experiencing limited acute stress may increase task performance and learning, excessive intraoperative stress can negatively influence surgeons' fine motor skills, coordination and dexterity, emotional state, focus, teamwork, communication skills, and decision‐making ability. ³ Ultimately, excessive stress can have deleterious effects on patient outcomes. ⁴ , ⁵ , ⁶

Previous research has attempted to measure surgeon stress through both biological responses and self‐reported measures of stress. ⁷ , ⁸ Under research conditions, known stressors can activate the sympathetic‐adrenal‐medullary axis as well as the hypothalamic‐pituitary axis, provoking release of pituitary and adrenal hormones including catecholamines which can then induce physiological changes in the cardiovascular and immune systems. ⁹ , ¹⁰ Measurable physiological responses including heart rate parameters, cortisol variations, sweat secretion, and immune proteins can be assessed in a surgical setting. ¹¹ However, accurate measurement of these markers in a live surgical environment under normal working conditions is more problematic. ¹²

Participant reported outcome measures (PROMs) offer an alternative pathway for assessing stress, since a critical factor in the stress response is perception. PROMs have been used in studies on surgeon education, ¹³ mental skills training, ¹⁴ and in comparisons of surgical approach. ¹⁵ , ¹⁶ , ¹⁷ The PROMs previously employed in studies of surgeon stress include Likert and visual analog scales of stress, ¹⁸ , ¹⁹ the Dundee Stress State Questionnaire, ²⁰ and the Spielberger State Trait Anxiety Inventory (STAI). ²¹ Whilst the STAI ²² and its 6‐item short form ²³ are the most commonly reported PROM in studies of surgeon stress, ⁸ these inventories were designed and validated as a measure of anxiety rather than stress. Although stress and anxiety share many of the same emotional symptoms, stress is caused by an external threat while anxiety is defined by persistent excessive worries that do not go away even in the absence of a stressor. ²⁴ The use of the STAI therefore may not have accurately captured the impact of a stressor in previous studies. In addition to the diagnostic difficulty of using the STAI to measure stress, the relationships between the time points around surgery and increased stress are unclear.

In this study, the primary aim was to identify whether there is a difference between anticipated stress and anxiety prior to an operation and the stress and anxiety perceived during surgery using PROMs. Secondary aims include assessment of differences based on level of training (resident vs. attending surgeons), the type of surgery performed, or the role each surgeon performs (primary vs. assistant operator); and if stress and anxiety scores are correlated.

2. MATERIAL AND METHODS

2.1. Study center and participants

This study was conducted at the Royal Hospital for Women, Sydney, Australia between 2018 and 2019 as part of a broader project investigating measures of biological stress in surgeons. ¹² This hospital serves as a tertiary referral center with extensive experience in undertaking minimally invasive gynecological procedures, including an established and certified training program in minimal access gynecological surgery. Attending gynecologists credentialled in procedures of interest within the hospital were invited to participate in the study. Residents in the obstetrics and gynecology program (6 years) at any level of training were invited to participate in their usual capacity as either assistant or primary surgeon. Prior to participation, surgeon data including date of birth, gender, body mass index, level of training (resident, attending gynecologist), years of surgical experience (<5, 5–10, >10), and number of hours operating each week (<10, 10–20, >20) were collected.

The study was conducted in “real world” situations and gynecologists were approached to participate at various times throughout the day. As such, no limitations were placed upon potential external stressors such as time constraints, sleep deprivation, dietary constraints, or undertaking more than one procedure in a day.

2.2. Surgical procedures

Three commonly performed minimally invasive gynecology procedures were selected for inclusion: Hysteroscopic myomectomy for any size myoma, total laparoscopic hysterectomy for uteri of at least 10 cm length on ultrasound, and laparoscopic excision of endometriosis where disease was graded as stage 3 or above based on the revised American Society of Reproductive Medicine (rASRM) staging. ²⁵ A total of 30 of each procedure was required to complete the study, with no limitation placed on the minimum or maximum number of surgeries any one attending gynecologist or resident surgeon could perform.

2.3. Self‐reported stress and anxiety measures

Each surgeon was invited to complete self‐reported measures of stress and anxiety prior to and after surgery. Presurgery responses were recorded immediately prior to scrubbing and post‐surgery responses were recorded once doffing was complete and before leaving the operating room. A visual analog scale (VAS) was completed where surgeons were asked to rate their perceived stress on a 100 mm non‐graduated line with the anchors 0 equal to “not at all stressed” and 100 equal to “very stressed”. The STAI is a two‐part, (STAI‐Y1 and STAI Y2) 40‐item, validated measure of generalized anxiety that distinguishes the contributions of dispositional anxiety and the transitory experience of anxiety to performance difficulties during testing situations. ²⁶ It requires participants to state their level of agreement with each item question on a 4‐point Likert‐type response from “not at all” to “very much so” with one to four points allocated. The sum of the responses creates an index of trait and state anxiety with scores ranging from 20 to 80. ²² The state component of the STAI evaluates feelings of apprehension, tension, nervousness and worry whilst trait anxiety refers to relatively stable individual differences between people in the tendency to perceive situations as dangerous or threatening. As trait anxiety can influence state anxiety, surgeons were invited to complete both components of STAI as well as VAS measures presurgery considering their anticipated stress and anxiety during surgery. Post‐surgery, they were asked to complete the state anxiety (STAI Y‐1) and VAS measures again regarding how they felt during surgery.

2.4. Statistical analyses

The sample size required for the biological outcomes study ¹² was calculated to be 30 procedures across the study to identify a significant difference in maximum heart rate over three distinct surgical procedures. Given the largest study to report baseline and intraoperative state anxiety scores demonstrated a mean score increase of 1.74 from baseline to surgery, ²⁷ the sample size was calculated to be sufficient to reproduce this difference in the state anxiety. Study data were collected and managed using REDCap electronic data capture tools hosted by Research Technology Services at UNSW Sydney and the statistical analysis was carried out using IBM SPSS version 26 (SPSS Inc, Chicago IL). Differences in surgeon demographic data between attending gynecologists and residents was assessed with a t‐test. Individual participant‐surgery episode changes were plotted and the significance of the change in paired data was assessed with the paired t‐test. One‐way analysis of variance was conducted to assess any differences based on type of surgery, role in surgery, and surgical experience and two‐way analysis of variance was performed to analyze the effect of level of training and role in surgery to the stress and state anxiety score. Correlation between stress and state anxiety was assessed with the Pearson correlation coefficient. Change in anxiety and stress scores from pre‐surgery to during are reported as mean change and 95% confidence intervals. Differences between groups are reported as mean ± standard deviation. Results were considered significant when p ≤ 0.05.

3. RESULTS

The study was completed by 17 participants, including 8/12 (67%) eligible attending gynecologists and 9 /11 (82%) resident gynecological surgeons (Table 1). None of the residents had previously been enrolled in other training programs. Attending gynecologists were significantly older than residents and had greater surgical experience. However, there was no difference in the proportion of women, body mass index, or the proportion performing surgery for more than 10 h per week. Residents commenced as the primary surgeon in 62 of 90 procedures (69%) with completion by attending gynecologists required in 28/62 (45%) of surgeries due to time constraints or surgical complexity. Trait anxiety scores (form STAI Y‐2) amongst all surgeons ranged from 20 to 52 out of 80 with a mean score of 33.7 ± 8.8. Residents reported significantly higher trait anxiety scores than attending gynecologists (39.8 ± 4.8 vs. 27.8 ± 7.7, p < 0.001); however, no significant trait anxiety differences were identified between types of procedure or operator.

TABLE 1.

Surgeon demographics.

Demographic	Overall		Attending gynecologist		Resident		p‐value
Participants n (%)	17		8	(47)	9	(53)
Mean age (SD)	38.9	(5.3)	42.9	(4.2)	35.2	(2.1)	0.01
Male gender, n (%)	5	(30)	3	(38)	2	(22)	0.78
Mean BMI (SD)	22.7	(2.7)	23.3	(3.3)	22.2	(2.1)	0.70
Surgical experience, n (%)
<5 years	8	(47)	1	(13)	7	(78)	0.01
5–10 years	5	(30)	4	(50.0)	2	(22)	0.01
>10 years	4	(23)	3	(37)	0	—
Operating hours per week, n (%)
<10	11	(65)	4	(50.0)	7	(78)	0.01
10–20	5	(29)	4	(50.0)	1	(11)	0.20
>20	1	(6)	0	—	1	(11)
Trait scores			27.8		39.8		0.001

Abbreviation: BMI, body mass index.

A total of 90 surgical procedures were undertaken as planned. All laparoscopic excision of endometriosis and laparoscopic hysterectomy procedures had a second surgeon present as either assistant and/or supervisor. Only 11/30 hysteroscopic myomectomy procedures required both an attending gynecologist and resident with the remaining 19 hysteroscopic myomectomies completed by attending gynecologists alone, or by residents alone where the attending gynecologist did not supervise the entire procedure. This resulted in 161 data sets (90 primary operator; 71 assistant) with pre‐ and post‐surgery self‐reported VAS of stress and STAI instruments completed for all 161 participant‐surgery episodes. Due to the nature of the training facility, the majority of procedures were performed by one attending gynecologist (41/161 procedures) and one resident (66/161) procedures; however, there were within‐surgeon variations for both state anxiety and self‐reported stress at pre‐ and post‐surgery and these did not statistically significantly vary between surgeons. A summary of surgery performed by surgeon is provided in Figure S1.

3.1. Differences in anticipated and recollected participant stress and anxiety

The mean recollected stress VAS increased by 3.9 from anticipated stress (95% CI: 1.1–6.8, p = 0.009) whilst the mean recollected state anxiety score increased by 4.4 (95% CI: 3.0–5.8, p < 0.001) from prior to surgery. The differences in stress and state anxiety scores were moderately correlated (r = 0.51, p < 0.001). Although a significant change was identified, the direction of change in stress was not uniform for either stress or state anxiety scores (Figures 1 and 2). Compared to anticipated stress, surgery was associated with an increase in perceived stress in 92/161 (57%) participant‐surgery episodes, a decrease in 66/161 (41%) and no change in 3/161 (2%). State anxiety reflected similar differences with an increase in 99/161 (62%) participant‐surgery episodes, a decrease in 52/161 (32%), and no change in 10/161 (6%) (Table 2). When stratified by experience, there was no significant mean difference between attending gynecologists and residents in differences of stress from baseline to surgery (5.5 ± 20.8 vs. 2.3 ± 19.5, p = 0.29) nor state anxiety scores (3.2 ± 9.5 vs. 5.3 ± 8.4, p = 0.13). Similarly, when stratified by primary operator compared to assistant there were no significant differences in the change of mean stress of primary operator compared to assistant (3.7 ± 21.2 vs. 4.219.2, p = 0.88) nor state anxiety (4.7 ± 9.1 vs. 3.3 ± 9.2, p = 0.35).

FIGURE 1.

Changes in anticipated to actual stress during surgery.

FIGURE 2.

Difference from presurgical state anxiety and recollected scores intraoperatively.

TABLE 2.

Absolute change in reported stress and anxiety scores.

	State anxiety (%)			Self‐reported stress (%)
	Increased	No change a	Decrease	Increased	No change a	Decrease
Cohort	99/161; 62%	10/161; 6%	52/161; 32%	92/161; 57%	3/161; 2%	66/161; 41%
Attending gynecologist	50/82; 61%	7/82; 9%	25/82; 31%	47/82; 57%	1/82; 1%	34/82; 42%
Residents	50/79; 63%	3/79; 4%	26/79; 34%	45/79; 58%	2/79; 3%	32/79; 40%
Primary	56/90; 62%	5/90; 6%	29/90; 32%	49/90; 55%	2/90; 2%	39/90; 43%
Assistant	43/90; 61%	5/71; 7%	23/71; 32%	43/71; 61%	1/71; 1%	27/71; 38%

^a Exact same score pre‐ and post‐surgery.

3.2. Presurgery anticipated stress and anxiety

Prior to surgery, VAS measure of anticipated stress in all participants ranged from 1 to 93 with a mean score of 39.53 ± 23.4 whilst the state anxiety score ranged from 20 to 57 with a mean score of 33.1 ± 8.9. Anticipated stress and state anxiety score were highly correlated (r = 0.68, p < 0.001). Mean anticipated stress score, but not state anxiety, was significantly higher prior to undertaking laparoscopic resection of endometriosis compared to hysteroscopic myomectomy. There were no other significant differences seen for either anticipated stress or state anxiety when stratified by procedural type. Table 3 summarizes the mean anticipated stress and state anxiety scores by type of procedure and all procedures.

TABLE 3.

Mean preoperative VAS and state anxiety scores by surgery.

Type of procedure	Stress mean (SD)	p‐value	Anxiety mean (SD)	p‐value
Endometriosis	45.8 (22.3)	—	33.7 (10.3)	—
Hysterectomy	39.1 (24.4)	0.14 a	33.6 (8.3)	0.96 a
Hysteroscopic Myomectomy	31.7 (21.6)	0.001 a	31.5 (7.7)	0.26 a
		0.12 b		0.21 b
All Surgeries	39.5 (23.4)	—	33.1 (8.9)	—
	Range 1–93 c		Range 20–57 c

^a Compared to laparoscopic excision of endometriosis.

^b Compared to laparoscopic hysterectomy.

^c Range of preoperative stress and anxiety scores across the study.

Abbreviations: SD, standard deviation; VAS, visual analog scale.

Self‐reported measures of anticipated stress stratified by operator demonstrated higher mean scores for primary surgeons compared to assistants for both anticipated stress (47.2 ± 24.3 vs. 29.9 ± 18.0, p < 0.001) and state anxiety (36.9 ± 8.7 vs. 28.3 ± 6.9, p < 0.001). Residents also reported higher levels of anticipated stress and anxiety compared to attending gynecologists (VAS 51.9 ± 20.5 vs. 27.8 ± 19.9, p < 0.001; state anxiety 38.3 ± 6.6 vs. 28.1 ± 7.6, p < 0.001). Two‐way analysis of variance was undertaken to assess for interaction between level of training and role in surgery for presurgical stress and anxiety. A significant association was identified for mean anticipated stress (p < 0.001) and state anxiety score (p = 0.001), suggesting that less experienced surgeons reported greater anticipated stress and anxiety when in a primary role compared to attending gynecologists. No significant correlation was seen between anticipated stress and state anxiety before surgery between primary operator and assistant.

3.3. Intraoperative stress

Following surgery, surgeons' scores assessing their recollection of stress experienced during surgery ranged from 3 to 96 with a mean score of 39.53 ± 24.9 whilst their recollected state anxiety score ranged from 20 to 71 with a mean score of 33.10 ± 11.8. Mean recollected intraoperative stress and state anxiety scores were highly correlated (r = 0.82, p < 0.001). Primary surgeons had significantly higher mean recollected intraoperative stress scores (50.4 ± 34.7 vs. 34.5 ± 20.5, p < 0.001) and state anxiety scores (41.3 ± 12.3 vs. 32.5 ± 9.1, p < 0.001) compared to assistants. Residents were similarly more likely to report higher recollected intraoperative stress (53.5 ± 23.4 vs. 32.7 ± 22.5, p < 0.001) and state anxiety scores (53.5 ± 10.6 vs. 31.7 ± 9.9, p < 0.001) compared to attending gynecologists. There were no significant differences in either the mean recollected intraoperative stress or state anxiety scales between types of procedures.

4. DISCUSSION

This study has shown there is a difference between anticipated stress and anxiety prior to surgery compared to what is experienced. In addition, we have identified a difference in baseline perceived stress and anxiety between primary and assisting surgeons, level of training, and complexity of surgery. These findings add to early small cohort studies reporting differences in stress based on 7‐point Likert scale ²⁸ , ²⁹ the DSSQ; ³⁰ , ³¹ , ³² however, this current study demonstrates feasibility to assess differences in perceived stress between types of surgery in a live surgical environment. In addition, no differences between primary and assistant surgeons nor differences in levels of training have been described using specific stress scales although STAI has been used to identify differences in surgeon training. ⁸ , ³³ These self‐reported measures stress observed in this study suggest that prior to any operation, surgeons may have already started considering the possible risks, actions, and adaptations that a given surgery will pose, with surgeons of lesser experience potentially anticipating greater stressors. Although a positive correlation between stress measured by a single‐item VAS and anxiety assessed by the STAI was identified, the strength of the association changed between prior to surgery and during surgery.

These observations of surgeons' stress and anxiety highlight the difficulties in predicting and measuring surgeon stress as well as the potential for misleading outcome data when using PROMs not designed and validated for stress. ⁷ Psychological stress reactions depend on the individual's cognitive ability to appraise and reappraise their environment, particularly to immediate and potentially significant risks, and their ability to make adaptive transactions with their environment to control for those risks. ³⁴ Appraisal requires decision making about whether any given action will be relevant to one's well‐being. ⁵ If it is producing harm, will it require immediate reversal or could it be tolerated? Could it lead to future harm or potentiate an outcome that may have a deleterious effect? These appraisals and the ability to mitigate harms will subsequently lead to central and system biological responses. Anxiety is a common neurobehavioral correlate of a variety of stress symptoms. ³⁵ Initially described as an unpleasant emotional state or condition characterized by ongoing feelings of tension, apprehension, nervousness, and worry, ³⁶ anxiety may reflect previous experiences of acute and chronic stressors and a lack of ability to adapt those stressors previously. Anxiety may trigger the autonomic nervous system in a similar way to the stress response; however, the key difference is that anxiety may occur in the absence of an identifiable threat/stressor.

A surgeon's presurgery appraisal of procedural threat, and therefore anticipated stress during surgery, is likely to be based on numerous factors including surgeon level of responsibility in the procedure, surgical complexity, and surgeon experience. ³⁷ , ³⁸ Differences therefore in anticipated compared to actual stress may reflect the mental preparedness of the surgeon to undertake the procedure, ³⁹ however, it may also represent the unanticipated difference in stressors such noise, unexpected anatomy, or injury. ⁴⁰ Presurgical anticipated anxiety likely reflects the same factors that influence anticipated stress. However, previous experience and trait anxiety can influence an individual's state anxiety despite the presence or absence of a stressor, potentially explaining the differences observed between stress and anxiety. Unexpected stressors of surgery may influence the difference from anticipated to actual stress in a single participant‐surgery episode and may be most beneficial when assessing such areas as trainee progress, operative approach, and operative equipment. In contrast, persistent differences for a given surgeon may provide insight to surgeons who are at risk of excessive stress and measures of anxiety may be more appropriate measure to reflect these longer‐term risks.

Although PROMs offer potential advantages over biological measures of stress they must be interpreted with caution. Measurement inaccuracies may arise from several sources including innate issues with the PROM itself, for example, central tendency and social desirability bias. ⁴¹ Surgeons' self‐reported measure of stress may also be influenced by their internal ability to respond to stressors. ⁴² The STAI is less likely to be affected by reporting biases compared to simplified scales as visual analogue scales and Likert scales, which likely contributes its more common usage in surgery; ⁸ however, it has not been designed to measure stress and clinical relevance, including cutoffs, is one of the difficulties in this area. In addition, the STAI was initially described to report dispositional and transient changes in anxiety. Although these emotional responses may be similar, they are not synonymous. Stress is considered the body's reaction to a threat or external trigger, whereas anxiety is the body's reaction to persistent or excessive stressors or worries. ⁴³

A major strength of this study is the assessment of both self‐reported stress and anxiety which has not been previously performed in a live surgery setting. Other strengths include successfully demonstrating the ease of use of self‐reported measures in stress research in live surgery, testing both primary and assistant surgeons, assessing differences between attending gynecologists and residents, and assessing three distinct elective surgical procedures. A further strength is that although participant sample size was comparable to previous studies ⁸ the total number of participant‐surgical episodes was substantively larger than previous studies. ¹³ , ²¹ , ⁴⁴

There were several limitations of this study. Due to the nature of the gynecology department in this center, one surgical team conducted most of the gynecological surgery over the study period. We did note individual variation with all measures; however, between individual differences were not apparent in this study. Differences in self‐reported stress and anxiety between residents and surgeons may therefore be influenced by individual differences rather than levels of training. In addition, the aim of the study was to understand stress responses in real‐world conditions. This created methodological limitations including not being able to assess the impact of trainee‐attending interactions (eg the attending gynecologist completing a procedure that was too complex for the resident), surgical team familiarity, and the inclusion of a study participant in more than one surgical event per day. These factors may have created confounding of perceived stress and anxiety scores both prior to surgery and during surgery. Future studies would require tighter inclusion criteria to assess the impact of these potential confounders. Due to real‐world conditions the study also did not account for stress effect modifiers such as time pressure, noise, or interruptions. ²³ Further limitations include an inability to describe the significance of a “threat” stimulus or identify which particular stimulus may cause a change in the perceived stress response.

Future research in this area should focus on the determinants of surgeon stress prior to surgery and identification of a normative range of PROM change from baseline to during surgery. Presurgery determinants of stress may include general stress reduction strategies such as meditation or mental skills training, or specific strategies such as mental preparation and surgical planning tools. Development of normative PROM ranges presurgery and during surgery may assist in identifying those surgeons who are at risk of progressing to maladaptive stress and implement surgeon health programs before that occurs.

5. CONCLUSION

Actual stress in surgery is greater than anticipated stress. Difference in anticipatory stress and anxiety between surgical operators and types of procedure is suggestive of surgeons undertaking presurgical appraisal of surgical threats, which is likely to develop with experience. More than two‐thirds of participant‐procedural events increased perceived stress; however, the significance of these stress differences observed and how they impact either patient or surgeon health remains unclear. Future research should focus on determinants of presurgical stress and when stressors become inhibitory to performance.

AUTHOR CONTRIBUTIONS

AKB: Conceptualization, methodology, data curation, analysis and writing. SS: Investigation and data curation. AH: Supervision and writing. CEW: Methodology and writing. JAA: Conceptualization, methodology, supervision and writing.

FUNDING INFORMATION

Dr Budden is supported by the Australian Government Research Training Program Scholarship for university tuition fees. Professor Wakefield is supported by the National Health and Medical Research Council of Australia (APP2008300).

CONFLICT OF INTEREST STATEMENT

The authors report no conflicts of interest.

6. Ethics statement

Ethical approval for this study was granted by the Local Human Research Ethics Committee (HREC ref no: 16/359; LNR/16/POWH/679) on March 22, 2017 and written informed consent was obtained from participants.

Supporting information

Figure S1.

Budden AK, Song S, Henry A, Wakefield CE, Abbott JA. Surgeon reported measures of stress and anxiety prior to and after elective gynecological surgery. Acta Obstet Gynecol Scand. 2024;103:360‐367. doi: 10.1111/aogs.14728