Stress kills

Around two-thirds of surgeons endure prolonged unrelieved stress, potentially undermining their physical and psychological health, leading to obesity, cardiovascular problems, depression and early death, said Prof Michaela Bayerle-Eder MD, PhD, Department of Clinical Pharmacology and Department of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria. “Stress perception and stress management are under-acknowledged in the surgical community and you need to be aware that you may be among those who are over-stressed,” she told the 37th Congress of the ESCRS in Paris, France. Prolonged stress leads to increased cortisol and catecholamine levels, she said. A potential consequence of that is metabolic syndrome. She noted that about one-third of young male surgeons suffer from obesity, one-third have impaired glucose tolerance leading to diabetes and more than 40% have lipid disorders. In addition, some estimates suggest that up to 68% of surgeons suffer from burnout and this is accompanied by depression that is mild-to-severe in up to 20%. In addition, around 15% of all surgeons are addicted to drugs. The stressors appear to have life-shortening effect. For, example a study of Brazilian neurosurgeons showed they had an average lifespan of only 68 years, Prof Bayerle-Eder pointed out. Another important aspect of stress is its effect on an individual’s relationships, she said. Stress reduces levels of testosterone and oestrogen resulting in reduced libido and fertility. Furthermore, research shows that stress can impair the amygdala, making one less cognizant of other’s emotions, as expressed in facial expressions and other non-verbal cues. In the classical model of stress, when confronted with a challenge, the stress levels rise, but as the challenge is overcome, the stress levels subside. However, a prolonged period of stress will result in burnout, when the stress reaction is replaced by a non-reactive apathy and resignation to stress. In the general adaptation stimulus model, a stressful stimulus leads to an alarm reaction, arising mainly from the brain stem and then there is a stress adapt reaction. This activates the hypothalamus pituitary adrenal (HPA) axis, increasing levels of cortisol and testosterone, adrenaline and dopamine, all of which can be beneficial when presented with a challenge. But again, when the stress adaptation reaction is prolonged it leads to burnout, Prof Bayerle-Eder explained. The fight-or-flight response tends to be more pronounced in males because it is mediated not only by norepinephrine and adrenaline but also by testosterone. Females generally have a more “tend and befriend” approach to problems and manage stress through socialising. That encourages the secretion of oxytocin, which is a relaxing and antidepressant hormone and is mediated by oestrogen. Under stressful conditions the hypothalamus causes the pituitary to release adrenocorticotropin hormone (ACTH) causing the adrenal cortex to release cortisol. There is also an activation of the sympathetic branch of the nervous system inducing fight-or-flight response through the release of epinephrine and norepinephrine. When a surgeon focuses on a procedure, they will have the classical release of norepinephrine and adrenaline as well as dopamine, which is the "endogenous cocaine" that provides the feeling of satisfaction that comes with meeting a challenge and accomplishing a task. Increased levels of acetylcholine further enhance their attention. “It is only the over-activation of this system that leads to the bad consequences,” she said. However, surgeons and others who have reached the burnout stage can recover a healthy and happy existence and, in the process, become a more able practitioner. Steps that might be taken to alleviate and prevent burnout include changes in diet and exercise to improve cardiovascular health and enhance sexual function. Maintaining a good social and sexual life is also important, to maintain good oxytocin levels. Good sleep hygiene is also necessary for optimal function, she added.

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