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.