Secondary Logo

Strategies to Increase Productivity, Improve Performance, and Decrease Stress Levels in Surgical Training

Perspectives From the Younger Generation

Wagner, Richard, MD*,†; Graydon, Colin, BSc; Deffaa, Oliver Johannes, MD*

doi: 10.1097/SLA.0000000000003179

*Department of Pediatric Surgery, University Hospital Leipzig, Leipzig, Germany

Department of Surgery, Division of Pediatric Surgery, Pediatrics & Child Health and Physiology & Pathophysiology (Adjunct), University of Manitoba and Children's Hospital Research Institute of Manitoba, Biology of Breathing Theme, Winnipeg, Manitoba, Canada

Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada.

Reprints: Richard Wagner, MD, Department of Pediatric Surgery, University Hospital Leipzig, Liebigstr. 20A, D-04103 Leipzig, Germany. E-mail:

The authors report no conflicts of interest.

Surgical training is a challenging and intense endeavor worldwide. It requires constant motivation, endurance, and personal sacrifice to become a good surgeon. On this path, many residents unfortunately experience burnout and report psychological, social, and physical sequelae. Especially in the field of surgery, these issues have to be named and discussed, since every year applicant numbers for surgical specialties decline.1 Stress levels for surgeons can be higher than other specialties due to the mere fact that surgeons spend a large portion of time in the operation room (OR) and yet are still expected to manage patient care, including ward rounds. But also, less obvious factors like uncertain work hours, strong hierarchies, or old surgical stereotypes may contribute to frustration among younger surgeons. Elevated stress levels may drive suicide rates that are higher among surgeons compared with other specialties.2 In addition, increasing administrative tasks in recent years are putting a higher demand on time and energy from young physicians, and this is also affecting their clinical training.

While novel psychologic and neuroscientific findings are applied relatively fast within big multinational companies to improve the working environment for their employees, in medicine, where these studies are often performed, the findings are implemented rather slowly and inconsistently. As an example, we know that extensive work hours lead to increased attentional failures and lower patient safety, but residents in many countries still have to work 24 hour-shifts.3 On the contrary, firms like Google or Uber acknowledge the importance of well-rested employees so much that they provide designated nap areas.

To develop strategies to improve training programs and resident satisfaction it is important to constructively and continuously address the issues that modern medicine is facing. But instead of waiting for a change in working hours, administrative duties, hierarchies and other external pressures, young surgeons should try to make present residency programs as beneficial as possible according to their own capacities. Good mentorship from experienced colleagues can help residents learn strategies to do exactly this. Indeed, surgical perspectives usually come from these attending physicians or department heads. However, residents can report first-hand how current residency programs influence their formation as physicians and how surgical training can be both, effective and enjoyable. We therefore aimed to present our ideas on how to directly improve training as surgical residents and how small changes in our daily routines can improve training, daily work performance, and satisfaction.

During surgical residency, unnecessary distractions can impair learning, teamwork, empathy with patients and management of demanding tasks at a high level. Smartphones, besides their obvious and well-advertised benefits, have many negative side effects. Distraction due to constant notification decreases our cognitive performance levels and can delay primary task completion by up to 4 times.4 Even the mere presence of a smartphone has the capacity to impair attention span and task performance.5 Given that most physicians carry their smartphone, and more recently smart watch, throughout the entire day, these can be game-changing insights for completing demanding tasks like writing a discharge letter or research paper or going on ward rounds and caring for patients. The OR may be the only place where modern surgeons go without their phone. The cognitive “flow state” that we experience in the OR can only be achieved if we focus on a task without constant interruptions. This might be one of the reasons why we enjoy the OR so much. By simply changing the notification settings on our devices to be more restrictive, we can limit the distraction from our smartphones and increase productivity and periods of focussed work.

One key skill for surgeons is to make good and responsible decisions quickly throughout our daily routines. Importantly, the quality of our decision-making deteriorates after a session of decisions, a phenomenon called “decision fatigue.”6 Wasting precious decisions on less important and shallow tasks (eg, social media) seems unfair to our patients and ourselves. In line with this, checklists can reduce mental overload by converting a series of tasks into an automatic process that ensures collaboration. We should push such strategies and establish working protocols if nonexistent, thereby facilitating life for us and others in the future.

To accomplish complex tasks efficiently and effectively, we need the ability to focus deeply. Behavioral research has shown that multitasking has both transient and lasting negative effects on the brain.7 Constant attention-switching diminishes our working memory and impairs our natural filters for irrelevant things. Given the fact that surgical routines sometimes require multitasking, we should keep additional multitasking (like checking emails and social media frequently) to a minimum. Instead of glancing at our social media or email-accounts during down times and between seeing patients, changing for the next surgery or while taking the stairs to the next floor, we should take a deep breath and relax psychologically for a few seconds. Using these short moments to unwind our brain will give us more cognitive power and presence for the upcoming task. The same applies to studying. We should ban all possible distractors and study with 100% focus instead of longer studying periods with fragmented attention. We should also consider the distraction we pose to colleagues and be conscious to use the communication method best suited to the situation. For an immediate response, call. Often extended text message conversations would be better addressed over a short phone call. Reserve texting for when they are unavailable (eg, in the OR), or you have a single semiurgent concern. For important nonurgent concerns, email, but do not expect an immediate response. Moreover, rather than texting our supervisors for single nonurgent matters, we should collect our questions throughout the day and solve them on a one-touch and face-to-face basis.

This leads to prioritization, a crucial aspect of clinical work, as exemplified in triaging patients for emergency care. A prioritizing mindset should also be more generally used for work in surgical routines. The Eisenhower matrix is a tool that can help prioritization by categorizing tasks in quadrants based on their urgency and importance.8 Using this strategy, urgent and important tasks should be done immediately, whereas urgent unimportant tasks should be delegated, although delegation is difficult in the clinical setting as a trainee. However, beyond clinical duties, prioritization is critical for writing scientific papers, conceiving standard operating procedures, studying, teaching, and addressing personal obligations. These little implementations will allow us and our colleagues to enter flow state easier and thereby save time and cognitive energy.

If we manage to use our working time effectively, we can subsequently allow our mind to rest from work without feeling guilty. This will allow us to spend quality time with our relatives and friends and to pursue hobbies, which can in turn boost our creativity. Innovations in patient care and medical research are essential for solving present and future challenges in medicine. Creativity as a basis for innovation requires freedom of time and mind, which unfortunately is often absent in resident daily clinical duties. Although seemingly contradictory, it is interesting to note that Nobel prize winners are more likely than other scientists to actively pursue hobbies such as poetry, music, or acting.9 In line with this, Google actively encourages their employees to use 20% of their time at their own proposal to do what they think could benefit the company most. This has resulted in innovative products such as Gmail.

In contrast to the damaging but still common surgical misconception that “sleep comes last,” we should pay attention to our sleeping habits to recover from a stressful day and, ultimately, to prevent the potential sequelae of sleep deprivation. In addition to the obvious effect of reduced energy, which itself leads to worse decision making, thought processing and concentration, sleep deprivation also greatly increases risk for obesity, cardiovascular disease, diabetes, and depression.10 As a consequence, it has been recognized as a public health problem by the Center of Disease Control and Prevention.10 Interestingly, sleep loss can also increase our susceptibility to distraction.11 While programmatic changes should strive to improve residents’ sleep hygiene, individual strategies such as reserving off-screen time before sleeping or being conscious of sleep duration can go a long way. Even the seemingly small change of not using the snooze feature, which takes tens of minutes that would be better spent on quality sleep, can have significant effects. Furthermore, morning routines like meditation, a short work out, and healthy breakfast promote health and improve productivity throughout the day.

Life as a surgeon is inevitably stressful due to its mere nature. By managing the stressors we can control, we can improve our quality of work and life. Conscious use of smartphone technology, focussed and undistracted work and sufficient dedicated time for recovery and creativity can thereby help us to increase productivity and the overall outcome of our training as a surgical resident. Although cognitive dissonance is hard to overcome and old habits difficult to change, we encourage the reader to translate awareness of the discussed issues into action.

Back to Top | Article Outline


The authors thank Richard Keijzer, MD, MSc, PhD, FACS and Guillermo Rocha, MD, FRCSC, FACS for their comments on the early versions of this manuscript.

Back to Top | Article Outline


1. Bartlett J. Addressing the recruitment shortfall in surgery—how do we inspire the next generation? Ann Med Surg 2018; 25:30–32.
2. Dimou FM, Eckelbarger D, Riall TS. Surgeon burnout: a systematic review. J Am Coll Surg 2016; 222:1230–1239.
3. Lockley SW, Cronin JW, Evans EE, et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med 2004; 351:1829–1837.
4. Leiva L, Böhmer M, Gehring S, et al. Back to the app: the costs of mobile application interruptions. Proc 14th Int Conf Human-Computer Interact with Mob Devices Serv Mob HCI 2012; 12:291–294.
5. Thornton B, Faires A, Robbins M, et al. The mere presence of a cell phone may be distracting implications for attention and task performance. Soc Psychol (Gott) 2014; 45:479–488.
6. Vohs KD, Baumeister RF, Schmeichel BJ, et al. Making choices impairs subsequent self-control: a limited-resource account of decision making, self-regulation, and active initiative. J Pers Soc Psychol 2008; 94:883–898.
7. Ophir E, Nass C, Wagner AD. Cognitive control in media multitaskers. Proc Natl Acad Sci 2009; 106:15583–15587.
8. Baer D. Dwight Eisenhower Nailed A Major Insight About Productivity. Business Insider. Available at: Published 2014. Accessed September 4, 2018.
9. Root-Bernstein R, Allen L, Beach L, et al. Arts foster scientific success: Avocations of Nobel, National Academy, Royal Society, and Sigma Xi members. J Psychol Sci Technol 2008; 1:51–63.
10. The Centers for Disease Control and Prevention. CDC – Sleep Home Page – Sleep and Sleep Disorders. Available at: Accessed September 5, 2018.
11. Blagrove M, Alexander C, Horne JA. The effects of chronic sleep reduction on the performance of cognitive tasks sensitive to sleep deprivation. Appl Cogn Psychol 1995; 9:21–40.

distraction; productivity; stress levels; surgical training; trainee satisfaction

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.