Anxiety and the surgeon

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the 12thman

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Just wanted to see what the communities thoughts are...

My situation...

5th year surgical subspecialty resident (last year in program). Good standing in program. I'm not the best, but I'm pretty sure I'm not the worst.

Clinic. Consults. Never an issue. I've been told I'm a safe physician and surgeon. No one has ever questioned my professionalism or clinical competency.

The problem...

The night before BIG procedures, I can't sleep well. I perseverate on getting stuck at key points of the procedure. Feel jittery, unable to concentrate.

If I know about a big case (even if 2-4 weeks from current date), my anxiety and symptoms kick into high gear. Sometimes, I'm secretly happy if something happens and a big case cancels.

Intraop - if things are going smoothly, I enjoy operating, get through no problem. When things aren't going well, or if I'm stuck, begin to feel a sense of "panic". Sweating. Impending sense of doom.

What I've done so far...

Been seeing a social worker. PRN Ativan (not much at all, probably 0.5 mg 1-2x per week). In cases, I've tried deep breathing while patient is being prepped. I've taken a step back from the patient, packed the field if bleeding and done some brief meditating/deep breathing before diving back in.

I feel like I have a strong social network. I'm committed to taking care of people. I just hate the anxiety I get before bigger surgical cases. Wanted to hear what people have gone through or seen. I'm too far along to "choose another specialty". I love my specialty.

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Have you tried an SSRI or propranolol?

I get pretty nervous before big elective cases in which a patient is neuro intact (I.e., there is a lot to lose) but am pretty calm with emergent cases unless there is something out of my control, like the time the elevetor to the lifeline copter wouldn't open to let 2 severely brain-injured kids into the hospital...I think some amount of anxiety is very appropriate. Try reading "Do No Harm" by the British neurosurgeon who talks about having had a similar issue for his decades of practice.
 
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Some of this may improve with time. But some will definitely not. What is your specialty?
 
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Ever try writing down what exactly you'd do in a big case and identifying a contingency for when you'd get stuck? I always feel more at ease knowing exactly what the hell I'll be doing. Personally, I'd stay the hell away from the controlled substances like benzos. Can't imagine they are defensible in court... but I guess you gotta do what you gotta do.

I've got nothing to base this off of, but sounds like you're an ENT and neck dissections are hilariously messy and potentially bloody -- like on irradiated/previously operated necks where the vessels are encased in scar... lol, oops, did i make a giant hole in the internal jug? Okay, cross clamp, cross clamp, prolene stitch please. Those kinda days do indeed require nerves of steel.
 
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I'm guessing ent too..some degree of anxiety is normal. It gets worse when you are a new attending. But with time and good outcomes comes confidence. I agree with whoever recommended thinking of contingency plans. Feeling all alone with no way out is an awful place to be.
If you are ent, you can practice our speciality without doing huge cases. Biggest case I routinely do is thyroids. And no shame in scrubbing those with a partner.
 
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I'm guessing ent too..some degree of anxiety is normal. It gets worse when you are a new attending. But with time and good outcomes comes confidence. I agree with whoever recommended thinking of contingency plans. Feeling all alone with no way out is an awful place to be.
If you are ent, you can practice our speciality without doing huge cases. Biggest case I routinely do is thyroids. And no shame in scrubbing those with a partner.

But in office balloon sinuplasties with those drug eluting stents bruh. So much reimbursement!
 
Lowly 'tern here, but FWIW, I think you're fine. I'd rather have a Nervous Nellie than some cowboy.

Have you tried mindfulness meditation or NLP? I highly recommend Miindfulness for Dummies as a starting point.

Also, one the attendings (a newbie) who is most loved by my co-residents and I, just about looks like he's going to pee his pants during tense moments of a case. I have even seen him call for help from a senior attending. He's brilliant, knowledgeable and a gifted teacher- he just hasn't been operating for 3 decades. No shame in it if it gets the job done.


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Having some anxiety is pretty normal.

Not sure I would recommend the ativan route. Beta blocker may be better.

If you haven't gotten your disability and life insurance situation taken care of, I would go ahead and do that now as well before doing anything else with medications.

A bit of fear is healthy, especially when starting out. I also agree with the other posters that mentally reviewing surgeries and steps you would take is good.

I try to review surgical videos as well and find it very helpful to mentally game plan for a case.

A few of my attendings regularly record their cases to submit for conferences but also for teaching purposes. It's a nice way to see how much you suck and continue to improve.

At the end of the day, anatomy and repetition are your friend.

Once your out, choose a good practice situation where you have collegial partners. They will scrub bigger cases with you and you will continue to learn. You won't be alone on an island unless you want to be.
 
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Thanks for the all responses. Sometimes medicine really can feel like you are on an island. I appreciate all your input. Really interesting hearing from people in residency to seasoned attendings.
 
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See a real shrink. You wouldn't trust a midlevel to operate on you and this is just as important. You also need a MD to back your use of Ativan in future credentialing.

This shouldn't derail your career. Anecdotally, one of my best fellows had similar struggles. That person still has the occasional rough day but is a great doc and I hope they will join my practice after leaving the military.
 
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I feel like a lot of this is normal, and like someone above said, gets worse when you're a new attending. However, it sounds like in your case it's physically disabling, and therefore justifies seeing an MD and getting some professional guidance.

I have a TON of anxiety about cases, and usually don't sleep that well the night before a big case. I definitely agree with the suggestion of writing down the steps you're gonna do beforehand. I also write down some reflections after each case, as it helps me decompress and be more confident for the next one. I also think it gets better with time (at least that's what I hear).

Good luck, and hang in there. I hear a lot of myself in your posts, and I can say it does suck. But I also think it's the sign of a good surgeon not to be pathologically over-confident.
 
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Just wanted to see what the communities thoughts are...

My situation...

5th year surgical subspecialty resident (last year in program). Good standing in program. I'm not the best, but I'm pretty sure I'm not the worst.

Clinic. Consults. Never an issue. I've been told I'm a safe physician and surgeon. No one has ever questioned my professionalism or clinical competency.

The problem...

The night before BIG procedures, I can't sleep well. I perseverate on getting stuck at key points of the procedure. Feel jittery, unable to concentrate.

If I know about a big case (even if 2-4 weeks from current date), my anxiety and symptoms kick into high gear. Sometimes, I'm secretly happy if something happens and a big case cancels.

Intraop - if things are going smoothly, I enjoy operating, get through no problem. When things aren't going well, or if I'm stuck, begin to feel a sense of "panic". Sweating. Impending sense of doom.

What I've done so far...

Been seeing a social worker. PRN Ativan (not much at all, probably 0.5 mg 1-2x per week). In cases, I've tried deep breathing while patient is being prepped. I've taken a step back from the patient, packed the field if bleeding and done some brief meditating/deep breathing before diving back in.

I feel like I have a strong social network. I'm committed to taking care of people. I just hate the anxiety I get before bigger surgical cases. Wanted to hear what people have gone through or seen. I'm too far along to "choose another specialty". I love my specialty.

Sounds like you're just a normal conscientious resident who is worried about making the jump to being an attending. To me, this is one of the critical parts to getting a job with good mentorship so you can call someone for help if necessary and can discuss tricky cases beforehand.

What is your concern about getting hung up on part of a case? What are some examples in which you've gotten stuck on some section and been unable to proceed? What was it about those sections that prevented you from going ahead? At those points, how does your faculty get you through it?

It seems normal to be anxious before a big case. Having said that, some people just aren't built for big whacks. You could tailor your practice as such.
 
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I second writing things down and going through the surgical procedure. The best way to combat this kind of performance anxiety is to prep beforehand.
 
Sounds like the anxiety is probably a little more than the usual anxiety of the conscientious senior resident about to be in charge of things, but not necessarily by a huge amount. I second the suggestion to see a doc and explore different medications (benzos just seem so dangerous compared to the benefits) and continuing to use behavioral techniques to battle the anxiety. Hopefully, knowing that lots of surgeons get nervous or anxious before big cases (even if not to the same degree) will help keep the anxiety from escalating (so you aren't anxious about being anxious).
 
I'm guessing ent too..some degree of anxiety is normal. It gets worse when you are a new attending. But with time and good outcomes comes confidence. I agree with whoever recommended thinking of contingency plans. Feeling all alone with no way out is an awful place to be.
If you are ent, you can practice our speciality without doing huge cases. Biggest case I routinely do is thyroids. And no shame in scrubbing those with a partner.
Any reason you'd guess ENT?
 
Well you said you are in 5th year of residency in a surgical subspecialty. That pretty much limits you to leaves ENT, uro, or integrated plastics or vascular. The others aren't 5 years or require fellowship training.

Could be helpful for those giving advice to know what you do. Any of those, except maybe for vascular would allow you to limit your practice to smaller cases. Do you even want to do big wacks in your career?
 
Well you said you are in 5th year of residency in a surgical subspecialty. That pretty much limits you to leaves ENT, uro, or integrated plastics or vascular. The others aren't 5 years or require fellowship training.

Could be helpful for those giving advice to know what you do. Any of those, except maybe for vascular would allow you to limit your practice to smaller cases. Do you even want to do big wacks in your career?
Yes I am an ENT resident.

I don't want to do much, if any cancer. I dread free flap reconstructions and especially taking care of patients with long hospital stays.

I enjoy smaller, quick procedures. I also enjoy endoscopic procedures.

I just feel bad that I detest a portion of my field so much and that it creates so much anxiety dealing with it. Looking around at my co-residents they all seem to be superstars.
 
Yes I am an ENT resident.

I don't want to do much, if any cancer. I dread free flap reconstructions and especially taking care of patients with long hospital stays.

I enjoy smaller, quick procedures. I also enjoy endoscopic procedures.

I just feel bad that I detest a portion of my field so much and that it creates so much anxiety dealing with it. Looking around at my co-residents they all seem to be superstars.

I dont really understand the problem. Just go into general and dont do anything above chipshot early stage cancer (or just refer them all out so you dont end up being one of those community guys that "dabble" in cancer and provide crap care). Or do any other subspecialty.
 
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I dont really understand the problem. Just go into general and dont do anything above chipshot early stage cancer (or just refer them all out so you dont end up being one of those community guys that "dabble" in cancer and provide crap care). Or do any other subspecialty.
Just wanted to hear other similar experiences and how people dealt with it.

I feel like we all carry around this machismo surgery mindset. It's good to hear the other side.
 
Looking around at my co-residents they all seem to be superstars.
As a psychiatrist who has sometimes treated other physicians, I can assure you: We all have private struggles even though most of us try our best to act like we have everything figured out when we're presenting a persona to the general public. I would be very surprised if your peers don't have their own insecurities or neuroticism that they are just trying to keep to themselves.
I echo the advice to consider trying to connect with a legit psychiatrist since there are many treatment options for anxiety issues like this. A psychiatrist may not be a surgeon, but chances are they'll understand better some of the issues of another physician than a social worker does. Hope things get better for you soon.
 
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Yes I am an ENT resident.

I don't want to do much, if any cancer. I dread free flap reconstructions and especially taking care of patients with long hospital stays.

I enjoy smaller, quick procedures. I also enjoy endoscopic procedures.

I just feel bad that I detest a portion of my field so much and that it creates so much anxiety dealing with it. Looking around at my co-residents they all seem to be superstars.

I wouldn't worry too much about it. Not everyone likes to do big surgeries. In ENT, you certainly don't have to. It's a lot different if you are going to take general surgery call and have to deal with free air, dead gut, etc. on a regular basis. In ENT there really isn't emergency stuff on call that is going to require you to do a major operation. If you want to focus on small cases and endoscopic work in your career... GO FOR IT! Nothing to be ashamed of. Everyone limits what they do in some fashion after residency. You will probably make more money and have a better lifestyle than the other hotshots in your residency. I bet 90% of practicing ENT's don't do major free flap reconstructions, by the way. The bubble of residency at a tertiary care hospital is a lot different than the types of pathology and cases you see in your average practice, even in a big city.
 
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the private ENT guys where I am pretty much limit themselves to tube and tonsils, any cancer stuff gets referred out. i don't even think they do trachs
 
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Just wanted to see what the communities thoughts are...

My situation...

5th year surgical subspecialty resident (last year in program). Good standing in program. I'm not the best, but I'm pretty sure I'm not the worst.

Clinic. Consults. Never an issue. I've been told I'm a safe physician and surgeon. No one has ever questioned my professionalism or clinical competency.

The problem...

The night before BIG procedures, I can't sleep well. I perseverate on getting stuck at key points of the procedure. Feel jittery, unable to concentrate.

If I know about a big case (even if 2-4 weeks from current date), my anxiety and symptoms kick into high gear. Sometimes, I'm secretly happy if something happens and a big case cancels.

Intraop - if things are going smoothly, I enjoy operating, get through no problem. When things aren't going well, or if I'm stuck, begin to feel a sense of "panic". Sweating. Impending sense of doom.

What I've done so far...

Been seeing a social worker. PRN Ativan (not much at all, probably 0.5 mg 1-2x per week). In cases, I've tried deep breathing while patient is being prepped. I've taken a step back from the patient, packed the field if bleeding and done some brief meditating/deep breathing before diving back in.

I feel like I have a strong social network. I'm committed to taking care of people. I just hate the anxiety I get before bigger surgical cases. Wanted to hear what people have gone through or seen. I'm too far along to "choose another specialty". I love my specialty.
bro you are in a very good specialty, because you can taylor your practice with great freedom. You've worked hard to get your position. Stay humble but remember why you are operating on a certain patient. Head and neck cancers are brutal.
 
bro you are in a very good specialty, because you can taylor your practice with great freedom. You've worked hard to get your position. Stay humble but remember why you are operating on a certain patient. Head and neck cancers are brutal.
Thanks! I definitely enjoy most of what I do.

As an update, I stopped taking Ativan PRN and sought actually therapy. It's been helpful reorganizing the way I cognitively approach surgeries and just life in general. I realized my coping mechanism was avoidance, which led to careful "manipulation" of OR schedules, how I counseled patients on rotations where I had control over pretty much everything.

If even 1 person reading this feels the same way, please seek help. Not only has it helped me, it's helped me better take care of patients as well. I'm looking forward to graduation and beyond.

Feel free to PM me as well!
 
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Thanks for the update.

ENT is a good field for your desires. We have ugly things that happen on call but luckily they are generally rare. Otherwise you can limit your practice to tubes, tonsils, FESS, septoplasty, open biopsy. You can refer head and neck cancer, thyroids, and parotids if you so desire. It's all what you want. Just be true to yourself and what you want from your career. Life is far too short to do what other people think you should do. Finally after all the struggle and hard work, you get to choose the next part. Make it what you want
 
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