From OR Stress to Decision Fatigue: A Surgeon’s Guide to Mental Fitness and Resilience

In a profession that prizes composure, precision, and control, the ACFAS session “Surgical Mental Fitness: Preventing Burnout in the OR and Beyond” pulled back the curtain on something rarely discussed openly in surgical culture: stress, emotional load, and the mental skills required to endure—and thrive—over decades in practice.

Following Dr. MaryEllen Brucato’s discussion on burnout (previously covered), the session shifted to three powerful themes: managing high-stress moments in real time, navigating difficult patient dynamics without losing yourself, and cultivating courage and resilience when life fractures your identity.

High-Stress Moments in the OR: Control What You Can

Lisa Levick-Doane, DPM, FACFAS grounded the conversation in a relatable scenario: a high-pressure OR moment when something goes wrong—an implant dropped, a missing instrument, a timeline collapsing.

The panel’s response was strikingly consistent:

• Pause. Step back. Reset.
• Have a backup plan.
• Regulate yourself before you react.

Surgeons described physically stepping away from the field (even for seconds) to regain cognitive control. The point was not theatrics, but physiology. Acute stress triggers sympathetic activation, said Dr. Levick-Doane: racing heart, narrowed thinking, reduced executive function. Without intervention, decision quality declines.

A recurring theme was cognitive load management. Surgical performance deteriorates when:

• Too many people are talking.
• Music is distracting rather than supportive.
• Equipment is missing or unfamiliar.
• Preoperative planning was rushed.

Working memory is finite. Preparation is protective.

Takeaway:
Mental fitness in surgery is not about eliminating stress—it’s about designing your environment and habits so stress does not hijack judgment. The panel stressed the value of preparation, rehearsal, quiet OR culture, and backup strategies to reduce preventable overload.

Decision Fatigue and Boundary Setting

Beyond the OR, speakers addressed an invisible contributor to burnout: decision fatigue.

After a full clinic and operative day, even trivial questions (“What do you want for dinner?”) can feel intolerable. That cognitive depletion is real—and cumulative. Levick-Doane and the panel emphasized two protective strategies:

Clear Boundaries with Patients. The “anxious postoperative patient” case generated one of the most practical discussions of the session.

Key strategies included:

• Setting explicit communication rules (what constitutes an emergency).
• Redirecting frequent callers to structured portals.
• Documenting thoroughly.
• Maintaining calm, firm tone.
• Avoiding defensive escalation.

More experienced surgeons acknowledged that early in practice, fear of upsetting patients often leads to boundary erosion. Over time, many learn that boundaries protect both surgeon and patient.

Red flags discussed included:

• Doctor-shopping behavior.
• Active family conflict (especially in pediatric cases).
• Untreated psychiatric instability.
• Patients who fundamentally do not trust the surgeon.

One pearl resonated strongly:

Just because you can operate doesn’t mean you should.

Saying “no” is often an act of professional maturity, not avoidance.

Emotional Transference and “Difficult” Patients

The panel explored how psychological distress can manifest physically. Chronic pain without correlating imaging, diffuse symptoms, escalating anxiety; many surgeons recognized these patterns.

Important insights from the panel:

• Sometimes reassurance, listening, and validation resolve more than intervention.
• Surgeons often seem to function as de facto therapists.
• Operating on emotional pain disguised as structural pathology rarely ends well.

This requires discernment—not cynicism.

AI and Administrative Load: Tool or Trap?

Harry Schneider, DPM, shifted the conversation toward systems-level burnout. His candid exploration of AI-assisted documentation highlighted both promise and caution.

The Promise:

• Significant reduction in after-hours charting.
• Faster operative reports.
• More time with family.

The Caution:

• AI mishears.
• It hallucinates.
• It mislabels anatomy.
• It misses empathy.
• It cannot replace clinical judgment.

The key message was intentional use. AI may reduce clerical burden, but surgeons must still review, edit, and ensure medical-legal accuracy.

Takeaway:
Reducing administrative friction is a legitimate wellness strategy, but automation cannot replace responsibility or human nuance.

Courage: When Identity Fractures

The emotional centerpiece of the session came from Dr. Weinraub’s personal story of surviving stage IV cancer after decades as a high-performing surgeon.

His narrative reframed resilience. From commanding OR teams to losing physical control. From authority to dependency. From certainty to existential doubt.

He described:

• The terror of medical vulnerability.
• The loss of identity.
• The unexpected strength drawn from colleagues and friends.
• The shift from efficiency to humanity.

His core message was simple but profound:

Resilience is not bravado. It is getting up—again and again—when life breaks you.

And equally important: You will not know when you are doing something for the last time.

That reminder—about meals, laps, conversations—landed heavily and poignantly in a room full of surgeons accustomed to postponing personal life for professional duty.

Core Take-Home Themes

1. Stress is physiological—not a character flaw. Learn to pause, regulate, and design environments that reduce cognitive overload.
2. Boundaries are professional skills. Protecting your time and emotional bandwidth improves patient care.
3. Not all pain is structural. Emotional distress often masquerades as pathology. Surgery is not always the solution.
4. Administrative burden drives burnout. Smart systems—including AI—can help, but must be used thoughtfully.
5. Resilience is practiced before it is needed. Community, humility, and gratitude matter more than stoicism.
6. You will not recognize the “last time.” Don’t postpone presence.

The Unifying Idea: Surgical Mental Fitness Is a Skill

This session reframed mental endurance as something trainable:

• Emotional regulation
• Boundary setting
• Cognitive load management
• Intentional technology use
• Meaning-making during crisis

Burnout prevention is not only about workload—it is about how we relate to stress, identity, and control.

And perhaps most importantly: Even surgeons need care, community, and courage.

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Podiatry Today or HMP Global, their employees, and affiliates.