Discussion
Key findings
This is the first study that we are aware of that looks at PA levels
amongst otolaryngologists. Our results suggest that performance anxiety
does exist amongst otolaryngologists, regardless of level of experience.
Our results have shown that female otolaryngologists are more likely to
have higher anxiety scores compared to males and this was statistically
significant. We did not find a difference in anxiety scores between
grade of surgeon. Furthermore this study highlights that whilst PA is
prevalent throughout otolaryngologists the effects it may have on
outcomes are unclear.
Comparisons with existing
literature
Gender and Performance
Anxiety
Our study found that females were more likely to have higher anxiety
scores than their male counterparts. Studies investigating PA in
musicians and professional athletes have alluded to similar results
(3,6,7). Although, similar to in our study they acknowledge there are
lower numbers of female professional athletes in studies than males.
Interestingly a study of professional athletes suggested that whilst
females had a higher perceived level of PA this didn’t impact on their
overall performance (3). Suggesting that females may be more likely to
identify as having higher levels of PA, but have improved coping
strategies.
Within medicine, studies in Serbia and the UK have found that female
medical students are more likely to rate their general stress status as
higher than males (8,9). Reasons suggested include lack of female role
models and conflict of interests with home life. It is not clear whether
having higher general levels of stress are transferable to a higher
level of PA and vice versa.
Effects of Performance
Anxiety
Physiological effects of PA can include rapid heart rate, tremor,
sweating and dry mouth meaning that PA experienced during surgical
procedures may result in physiological arousal (1). We are unable to say
what effects PA may have on performance outcomes, as there is very
little information available on this. One study investigating the
effects of PA amongst professional rock climbers suggested that those
participants with higher PA put in more effort and therefore performed
better (10). Furthermore an investigation within netballers suggested
that higher perceived PA levels were linked to improved performance
(12). However, an experiment involving laparoscopic operating showed
that a higher heart rate was associated with a greater number of errors
amongst novice surgeons (13).
There may be a peak performance area that is linked to a certain level
of PA. This is supported by the Yerkes-Dodson law which suggests that
the link between physiological arousal and performance is an inverted U
shape (11), implying there is worse performance at times of low and high
arousal. Understanding how to achieve this optimal level of PA may allow
us to target this area, improving surgical outcomes and training.
Qualitative research amongst musicians suggests that those who manage
their PA best accepted it as a positive aspect of performing and used
pre-performance visualisation and aspects of cognitive behavioural
therapy to manage it (14). Wetzel et al found that with experience
surgeons developed sophisticated coping strategies for managing PA (15)
and can be taught to others
We know that there is a link between anxiety and burn out amongst
medical professionals but it is not clear whether PA in surgeons may
also contribute to stress and burn out (16). Amongst musicians it has
been shown that PA may cause significant stress and affect career
outcomes (7).
Strengths and limitations
We accept there are limitations within this study. These include low
sample size, which may result in a sampling bias. However, this research
is the first of its kind to review PA amongst otolaryngologists and
provides a snapshot of prevalence. Respondents might not have answered
honestly, as this was an online questionnaire it would be difficult to
ascertain this. However the questionnaire has 5 questions that aren’t
counted towards the final SCAT score, which would reduce the internal
response-set bias making this less likely.
Finally, there are no questionnaires validated within surgery to
evaluate PA and therefore we have adapted a sports PA questionnaire.
Within this study we highlight that PA is prevalent within
otolaryngology, a relatively unknown issue that is only recently being
considered as an issue for surgeons.
Implications for research/
practice
There is a growing body of research suggesting that stress and
psychological symptoms can lead to reduced morale and burn out amongst
healthcare workers (17). Working out how PA may contribute to external
stress and burn out amongst surgeons may help us to better support these
doctors.
Research is needed to further understand the relationship between PA and
surgical outcomes. Research suggests that female professional athletes
are more likely to be negatively impacted by the perceived motivational
climate created by their coach (3). Understanding how different surgeons
react to their environmental climates, whether they are male or female,
may help to identify how they prefer to operate, which would have
implications for optimal teaching methods.
Finally, we did not draw any differentiation between elective and
emergency procedures within our questionnaire. It is well understood
that emergency scenarios may cause more stress and anxiety to the
surgeon (15) and therefore further research is required to investigate
how PA may affect this.
Conclusions
This study highlights PA is prevalent amongst otolaryngologists,
regardless of experience. We have identified that females are more
likely to have higher levels of anxiety compared to males.. We advocate
that training and discussion of coping strategies for managing the
effects of PA should be incorporated into training and continuing
professional development.