Mindfulness can be described as the state in which one is to be fully present in the moment, which draws parallels with surgery. The origins of mindfulness stem from ancient Buddhist traditions, and its utilisation in recent times in the military, sports science and more has increased [1].
However, its effects in the operating room have been studied relatively little. Cataract surgery has been shown to exert variable levels of stress and anxiety on ophthalmology doctors in training (DiT) and consultants alike [2]. With ever-increasing operating pressures, waiting lists, and distractions of the modern world, mindfulness in cataract surgery may be more important than ever for our patients and for our mental wellness.
Aim
To assess ophthalmology DiT self-reported cataract surgery experiences before and after a four-week period of utilising mindfulness exercises to assess whether these had a beneficial effect.
Figure 1: Likert questionnaire at baseline and four weeks.
Method
An observational prospective cohort study where Northern deanery ophthalmology DiT cataract surgery experience was measured at baseline using a questionnaire assessing feelings of enjoyment, anxiety, focus, relaxation and distraction, based on a typical operating list. The Likert questionnaire scaled each response from 1, a fully negative experience, to 7, a fully positive experience (Figure 1). Following completion of the baseline questionnaire, the ‘Phaco Mindful Toolkit’ (developed by the author) was disseminated to the DiT (Figure 2). The toolkit included resources of suggested mindful practices to utilise including breathwork, visualisation and positive affirmation. The commercially available smart-phone app and website Headspace (https://www.headspace.com) was utilised for many of the resources in the toolkit. A repeat questionnaire was completed after a period of four weeks with additional questions.
QR CODE: https://youtu.be/a7uQXDkxEtM?si=U5091KApNOl6wM3C
QR CODE: https://www.youtube.com/watch?v=Vtgv3RtZbIg
Figure 2: The Phaco Mindful Toolkit.
Results
All 22 ophthalmology DiT completed both the baseline and four-week follow-up questionnaires, meaning there was no attrition rate. There was an even spread of DiT grades participating, which included all years of speciality training from year one to seven. All 22 DiT had participated in at least one operating list over the four-week study period and 55% (12/22) had participated in three or more lists.
Figure 3: Mean response to feelings of relaxation during an operating list.
The most significant finding was the improvement of feelings of relaxation during an operating list, mean DiT scores were 4.41/7 (SD 1.14) and 5.09/7 (SD 0.97) at baseline and follow-up respectively, a positive increase of 15% (Figure 3). Furthermore, there were modest improvements in feelings of anxiety toward the next operating list, mean DiT scores were 5.09/7 (SD 1.74) and 5.59/7 (SD 1.14) at baseline and follow-up respectively, a positive increase of 10%. Questions regarding enjoyment, focus, distraction showed minimal change from baseline to follow-up.
At follow-up, 77% (17/22) of DiT agreed that the mindful toolkit improved their overall cataract experience
Discussion
The toolkit developed for this study was centred on three key mindful concepts:
- Breathwork
- Visualisation
- Positive affirmation
Breathwork is a cornerstone to mindfulness and involves simply focusing on every breath in and out, together with the accompanying movement of the chest.
Numerous papers have found focused breathwork to decrease stress, lower blood pressure, and regulate the autonomic nervous system, amongst other benefits [3]. The combined benefits of breathwork may allow a surgeon to approach a list with an increased feeling of focus and calmness. Furthermore, focused breathing is free, non-pharmacological and can be utilised nearly anywhere, even mid-way through an operating list.
Visualisation, or mental imagery, is “the cognitive rehearsal of a given task in the absence of physical movement” [4]. This purely cerebral technique has been well documented for years to have effective outcomes in sports athletes, musicians and dancers [5,6]. A recent randomised study investigating visualisation in surgeons prior to undertaking a simulated gastric operation found those practising visualisation performed superiorly overall compared to those who did not [7]. Crystalising the steps of cataract surgery in one’s mind before executing them is likely to reduce stress prior to operating and possibly improve performance. This is especially true for the first case on a list, for an atypical case or after a period of absence from the operating room.
Positive affirmations are positively loaded thoughts or statements to challenge unhelpful or self-sabotaging thoughts, which can occur during or after surgical difficulties. Complications are known to cause variable negative psychological impacts on a surgeon, and can affect their surgical ability, social life and relationships [8]. Fostering positive affirmation can improve perceived wellbeing and resilience, which gives the surgeon the ability to reduce negative psychological impacts associated with surgical difficulties such as complications [9].
Conclusion
The practice of mindfulness in the approach to cataract surgery appears to benefit ophthalmology DiT experience, particularly in terms of feelings of relaxation, anxiety and impatience. The practice of mindfulness may also be of benefit in other surgical specialties during training.
References
1. Brewer J. Mindfulness in the military. Am J Psychiatry 2014;171(8):803–6.
2. Ansari AS, Tung ASW, Wright DM, et al. Stress and cataract surgery: A nationwide study evaluating surgeon burnout. Eur J Ophthalmol 2023;3:11206721231154611.
3. Hopper SI, Murray SL, Ferrara LR, Singleton JK. Effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults: a quantitative systematic review. JBI Database System Rev Implement Rep 2019;17(9):1855–76.
4. Driskell JE, Copper C, Moran A. Does Mental Practice Enhance Performance? J Appl Psychol 1994;79(4):481–92.
5. Cocks M, Moulton CA, Luu S, Cil T. What surgeons can learn from athletes: mental practice in sports and surgery. J Surg Educ 2014;71(2):262–9.
6. Bolles G, Chatfield SJ. The Intersection of Imagery Ability, Imagery Use, and Learning Style: An Exploratory Study. J Dance Educ 2009;9(1):6–16.
7. Souiki T, Benzagmout M, Alami B, et al. Impact of mental imagery on enhancing surgical skills learning in novice’s surgeons: a pilot study. BMC Med Educ 2021;21(1):545.
8. Siddaiah-Subramanya M, To H, Haigh C. The psychosocial impact of surgical complications on the operating surgeon: A scoping review. Ann Med Surg (Lond) 2021;67:102530.
9. Benzo RP, Kirsch JL, Nelson C. Compassion, Mindfulness, and the Happiness of Healthcare Workers. Explore (NY) 2017;13(3):201–6.
Declaration of competing interests: None declared.
