Saturday, October 29, 2016

Stress and Comfort zones- with Dan Kuhn

Stress and Comfort zones- with Dan Kuhn

General Surgery News recently published a piece titled “When a Stressful Event Sticks Traumatic Stress Disorders Can Plague Surgeons; Psychiatrist Describes Technique Helpful in Erasing Ill Effects “ (an interview with Daniel Kuhn, psychiatrist) The topic meshes well with other discussion I have had on physician/surgeon resiliency (  In this editorial Dr. Kuhn relates that when the Yom Kippur war erupted in Israel he returned home to serve as a physician in the Israeli Army. It was in this role that he detected a pattern amongst those who suffered from PTSD. He realized that the traumatic event takes over the victims mind and they become obsessed with that event to the point that they can no longer function. Trauma is associated with anger, fear and helplessness which tighten the disruptive cycle. As a cellist he discovered performance inconsistencies so he developed a technique that disrupts that cycle. When his practice was developing he detected a pattern similar to that, in Surgeons. Surgeons tend to bury stress and fixation on error. 

Surgeons face stressful conditions and unpredictability on a frequent basis. In his book Forgive and Remember, Bosk, describes the difficulties in a Surgeon’s professional life in handling failure. Essentially our patients and peers (and us) expect surgery to be a quick fix compared to medical therapy of disease. When the outcome is not perfect doubt begins to creep in. If the surgeon does not elicit help or find a solution to break the cycle, then inevitably, performance will be negatively affected.

Several recent studies have highlighted the risk for PTSD in Trauma Surgeons and Surgical trainees (Journal of Trauma and Acute Care Surgery 2014;77:148-154;  Surgeon 2015. pii: S1479-666X[15]00099-2). surgical trainees have been shown to have higher rates of psychological distress than the general population (10% reported PTSD symptoms lasting more than one month) In the Journal of Trauma and Acute Care Surgery Study  40% of trauma surgeons relayed symptoms of PTSD (15% met the diagnostic criteria for PTSD). This risk was increased with the following factors:

·         Male trauma surgeons operating on more than 15 cases per month

·         more than seven call duties per month

·         less than four hours of relaxation per day

Back in Dec 2015 Carol-Ann Moulton and I discussed a paper their Toronto group published in the Annals of Surgery on Comfort Zones and Risk Taking in Surgery (Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone. Ann Surg. 2015); Details of that conversation are at In our discussion of the interviews which led to their publication it appeared that even the boldest appearing surgeons probably have a breaking point.  It is likely that every surgeon has a perception of where their boundary is; the place where they no longer feel comfortable.  Self-assessment literature seems to indicate that we frequently do not openly acknowledge that we have a comfort zone (or may not accept that personally). It may be that the temperamental and angry affect we see in some surgeons is actually a reflection of anxiety. It is unlikely that anyone is immune, but we simply do not discuss it. 

I had some questions for Dr. Kuhn:

·         Surgeons are more likely to not acknowledge they are stressed, burned out or in a PTSD state. What are the key symptoms I should be relating to my comrades that indicate they have a high likelihood of having entered or on the cusp of a PTSD state?

·         If they have not quite reached that point, what is your advice to prevent their potential situation from worsening?

·         How do I approach a colleague who I think is either on the cusp of or in a PTSD state?

·         If I am diagnosed and then recover from a PTSD state, are their triggers that I will need to keep away from to avoid a relapse?

·         Without giving your secrets away could you simply describe your technique that you have perfected in dealing with this?

·         Is there a point of no return where you would look at someone and simply state that an alternate career should be a high consideration?

·         Are we genetically predisposed to obsession and PTSD? That is why do some people seem to be teflon coated and let stress run off of them?

Any familial risk?

Bosk CL. Forgive and Remember: Managing Medical Failure. 2nd ed. Chicago, IL: University of Chicago Press; 2003

Zilbert NR, Murnaghan L, Gallinger S, Regehr G, Moulton C. Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone. Ann Surg. 2015; 262(2):253-259.

Kenneth A. Lipshy, MD, FACS

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