Elsevier

The Surgeon

Volume 15, Issue 3, June 2017, Pages 123-130
The Surgeon

Post-traumatic stress disorder amongst surgical trainees: An unrecognised risk?

https://doi.org/10.1016/j.surge.2015.09.002Get rights and content

Abstract

Background

Experiences of actual/threatened death or serious injury to patients are commonplace in surgery. Pathological symptoms following stress may lead to Acute Stress Reaction (ASR) and Post-Traumatic Stress Disorder (PTSD). PTSD symptoms of insomnia, anger, poor concentration, hyper-vigilance and exaggerated startle have implications for patient safety. The current study investigates the prevalence of occult, untreated psychological morbidity amongst surgical trainees.

Methods

A web-based survey of UK surgical trainees based upon the Impact of Events Scale-Revised (IES-R) was distributed using social media platforms and email. A score of ≥33 was indicative of ASR or PTSD (the former lasting <1 month, the latter >1 month). Additional questions concerned chronicity of symptoms, mentorship, team-working and access to support.

Results

For 167 returned surveys the mean age was 32.7 (SD 3.6) years; 102/167 (61%) were male. Mean years in training were 6.1 (SD 3.6). Median IES-R score was 14 (IQR 7–23.5). Of 144 respondents who answered about stress symptoms, 23/144 (16%) had IES-R score ≥ 33; 6 of these had symptoms < 1 month (suggesting ASR); 17 had symptoms lasting >1 month (suggesting PTSD). Those with IES-R ≥ 33 group were more likely to have repeated years of training, and have witnessed severe pain, traumatic injury, and acute haemorrhage. Seven with score ≥ 33 had sought support.

Conclusion

Occult psychological morbidity amongst surgical trainees may be higher than in the general population. Recognition and management of this risk is important for the mental health of trainees and the safety of patients.

Introduction

As they manage patients experiencing acute pain, life threatening emergencies and death, surgeons may experience distress, fear and acute stress both in themselves and their patients as well as guilt associated with their responsibility for any of these patient experiences. Although the majority of these experiences are cognitively processed in the same manner as other memories, pathological symptoms such as irritability, hypervigilance and intrusions (flashbacks or nightmares) may also develop. The Diagnostic and Statistical Manual Version 5 (DSM-V) outlines what may be classed as a sufficiently “traumatic” experience that may lead to Acute Stress Reaction (ASR) and Post-Traumatic Stress Disorder (PTSD). The first of these, Criterion A, includes the witnessing in person actual or threatened death or serious injury to another person. Such experiences are commonplace during the career of most surgeons. There is an expectation that surgeons will continue to deliver care despite preceding stressful events, or even that such events might enhance the surgeon's ability to deliver care in stressful settings. However, a recent survey of American trauma surgeons found that 15% met the criteria for PTSD,1 which is higher than the expected level in the general population (5.6% lifetime prevalence).2 Interviews of surgeons have demonstrated that feelings of guilt, crisis of confidence and anxiety, coupled with sleep disturbance and physical reactions may follow complications.3 Subsequent complaints and litigation may further compound these reactions.4

If symptoms of reliving the traumatic event (intrusive memories), feeling on edge (hypervigilance), negative thoughts and mood, and urges to avoid reminders of the traumatic event last for less than a month, it may be classed as ASR. When symptoms persist for over a month, this is indicative of PTSD. People experiencing PTSD may also struggle with sleep, suffer with outbursts of anger, have poor concentration, or have an exaggerated startle response.5 Such symptoms are of obvious concern for the practice of surgeons, since they may impact on their safety and competence, which can result in potential risk to patients. Addressing this psychological morbidity is of further concern when it is put into the context of known risk of burnout,6 unhelpful coping strategies such as alcohol and substance abuse,7 and suicide8 amongst surgeons.

We hypothesised that there might be an elevated prevalence of occult, untreated PTSD amongst surgical trainees who have experienced stressful events as part of their work. The aim of this study was to examine the prevalence of PTSD in a cohort of trainee surgeons, to establish the proportion accessing treatment and/or barriers to this. Appropriate support and care for the mental health of surgical trainees who are continually exposed to potentially traumatic experiences may be a neglected part of surgical training. Such a finding may prompt more focussed attention towards the psychological well-being of this population at risk.

Section snippets

Study design

UK surgical trainees were invited to participate in a non-mandatory, self-administered anonymous survey study that utilised a 28-point questionnaire. Research Ethics Committee approval was not required for this study, as confirmed by the decision-making tool on the online National Research Ethics Service (www.nres.nhs.uk).

Questionnaire details

A survey was created to include questions regarding subjects' demographics (gender, age, ethnicity), and training details (UK Deanery, year of training, years since graduation

Questionnaires

There were 225 questionnaires returned, of which 167 fulfilled the inclusion criteria of being UK-based surgical trainees. The remainder were excluded due to being non-UK (n = 14), non-trainee grade (n = 6), and non-surgical (n = 38). All surveys were returned from April to June 2015. Response rate was not calculated since there was no method of tracking the denominator of subjects who had access to the questionnaire. Of all included UK surgical trainee respondents, 144/167 (86%) answered at

Discussion

The primary finding of this questionnaire-based study of UK based surgical trainees is that 16% of subjects had pathological symptoms consistent with ASR or PTSD according to psychological screening. Furthermore less than a third of these subjects had sought professional support for their symptoms. This is the first study to examine this occult phenomenon in UK based surgical trainees. The study findings are consistent with the US-based study showing similar prevalence of pathological symptoms

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