Evaluation of Stress Levels of Trainee Cardiac Surgery Residents during Training Interventions Using Physiological Stress Parameters
Abstract
:1. Introduction
- The extent to which stress levels affect heart rate variability (HRV) in trainee cardiac surgeons.
- The difference in stress levels between junior surgeon trainees and senior surgeons during cardiac surgery teaching procedures.
- Whether preventive and health-promoting measures can be derived from the resulting findings and conclusions can be drawn for clinical practice, for example, in terms of arranging the operating room schedule.
- Which valuable findings regarding stress should be generated for occupational groups in the context of occupational medicine and science.
2. Study Design and Sample Description
3. Methodology, Heart Rate Variability Analysis, and Sample Description
Statistical Analysis
4. Results
5. Discussion
6. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- von Voltmer, E.; Kieschke, U.; Spahn, C. Arbeitsbezogenes Verhalten und Erleben bei Ärzten im dritten bis achten Berufsjahr. Z. Psychosom. Med. Psychother. 2007, 53, 244–257. [Google Scholar] [CrossRef] [PubMed]
- von dem Knesebeck, O.; Klein, J.; Frie, K.G.; Blum, K.; Siegrist, J. Psychosocial stress among hospital doctors in surgical fields: Results of a nationwide survey in Germany. Dtsch. Arztebl. Int. 2010, 107, 248–253. [Google Scholar] [CrossRef]
- Pereira, D.; Müller, P.; Elfering, A. Workflow interruptions, social stressors from supervisor(s) and attention failure in surgery personnel. Ind. Health 2015, 53, 427–433. [Google Scholar] [CrossRef] [Green Version]
- Kern, M.; Buia, A.; Tonus, C.; Weigel, T.F.; Dittmar, R.; Hanisch, E.; Zapf, D. Psychische Belastungen, Ressourcen und Wohlbefinden von Chirurgen in Deutschland: Eine Querschnittsstudie. Der Chirurg 2019, 90, 576–584. [Google Scholar] [CrossRef] [PubMed]
- Kivimäki, M.; Virtanen, M.; Vartia, M.; Elovainio, M.; Vahtera, J.; Keltikangas-Järvinen, L. Workplace bullying and the risk of cardiovascular disease and depression. Occup. Environ. Med. 2003, 60, 779–783. [Google Scholar] [CrossRef] [Green Version]
- Huth, C.; Thorand, B.; Baumert, J.; Kruse, J.; Emeny, R.T.; Schneider, A.; Meisinger, C.; Ladwig, K.-H. Job strain as a risk factor for the onset of type 2 diabetes mellitus: Findings from the MONICA/KORA Augsburg cohort study. Psychosom. Med. 2014, 76, 562–568. [Google Scholar] [CrossRef]
- Unrath, M. Psychische Gesundheit von Ärzten in Deutschland: Prävalenz psychischer Erkrankungen und Risikofaktoren. Hessisches Ärzteblatt 2012, 2, 86–90. [Google Scholar]
- Beschoner, P.; Limbrecht-Ecklundt, K.; Jerg-Bretzke, L. Psychische Gesundheit von Ärzten: Burnout, Depression, Angst und Substanzgebrauch im Kontext des Arztberufes. Nervenarzt 2019, 90, 961–974. [Google Scholar] [CrossRef] [PubMed]
- Anton, N.E.; Montero, P.N.; Howley, L.D.; Brown, C.; Stefanidis, D. What stress coping strategies are surgeons relying upon during surgery? Am. J. Surg. 2015, 210, 846–851. [Google Scholar] [CrossRef]
- Brunner, S.; Kröplin, J.; Meyer, H.-J.; Schmitz-Rixen, T.; Fritz, T. Einsatz chirurgischer Simulatoren in der Weiterbildung—eine deutschlandweite Analyse. Chirurg 2021, 92, 1040–1049. [Google Scholar] [CrossRef] [PubMed]
- Thielmann, B.; Boeckelmann, I. Herzfrequenzvariabilität als Beanspruchungsindikator für psychische Belastungen bei Chirurgen—ein Literaturüberblick. Zentralblatt für Chirurgie 2016, 141, 577–582. [Google Scholar] [CrossRef] [PubMed]
- Sammito, S.; Thielmann, B.; Seibt, R.; Klussmann, A.; Weippert, M.; Böckelmann, I. Nutzung der Herzschlagfrequenz und der Herzfrequenzvariabilität in der Arbeitsmedizin und der Arbeitswissenschaft: Reg-Nr. 002-042. 2014. Available online: https://www.awmf.org/uploads/tx_szleitlinien/002-042l_S2k_Herzschlagfrequenz_Herzfrequenzvariabilit%C3%A4t_2014-07.pdf (accessed on 12 November 2021).
- Sammito, S.; Sammito, W.; Böckelmann, I. The circadian rhythm of heart rate variability. Biol. Rhythm. Res. 2016, 47, 717–730. [Google Scholar] [CrossRef]
- Bundesärztekammer. Bundesärztekammer. (Muster-)Weiterbildungsordnung. 2018. Available online: https://www.bundesaerztekammer.de/fileadmin/user_upload/downloads/pdf-Ordner/Weiterbildung/20210630_MWBO_2018.pdf (accessed on 1 November 2021).
- Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Heart rate variability: Standards of measurement, physiological interpretation and clinical use. Circulation 1996, 93, 1043–1065. [Google Scholar] [CrossRef] [Green Version]
- Niskanen, J.-P.; Tarvainen, M.P.; Ranta-Aho, P.O.; Karjalainen, P.A. Software for advanced HRV analysis. Comput. Methods Programs Biomed. 2004, 76, 73–81. [Google Scholar] [CrossRef]
- Tarvainen, M.P.; Niskanen, J.-P.; Lipponen, J.A.; Ranta-Aho, P.O.; Karjalainen, P.A. Kubios HRV-heart rate variability analysis software. Comput. Methods Programs Biomed. 2014, 113, 210–220. [Google Scholar] [CrossRef] [PubMed]
- Sammito, S.; Böckelmann, I. Analyse der Herzfrequenzvariabilität. Mathematische Basis und praktische Anwendung. Herz 2015, 40 (Suppl. 1), 76–84. [Google Scholar] [CrossRef]
- Tarvainen, M.P.; Lipponen, J.A.; Niskanen, J.P.; Ranta-Aho, P.O. Kubios HRV (ver. 3.5) User’s Guide: ©Kubios Oy. 2021. Available online: https://www.kubios.com/downloads/Kubios_HRV_Users_Guide.pdf (accessed on 12 November 2021).
- Thielmann, B.; Pohl, R.; Böckelmann, I. Heart rate variability as a strain indicator for psychological stress for emergency physicians during work and alert intervention: A systematic review. J. Occup. Med. Toxicol. 2021, 16, 24. [Google Scholar] [CrossRef]
- Mandegar, M.H.; Saidi, B.; Roshanali, F.; Alaeddini, F. A Comparison of Cardiac Surgeon’s Stress Level During Off- Pump and On-Pump CABG by Cardiac Variability Indices, A Case-Report. J. Clin. Exp. Cardiol 2010, 1, 112. [Google Scholar] [CrossRef]
- Demirtas, Y.; Tulmac, M.; Yavuzer, R.; Yalcin, R.; Ayhan, S.; Latifoglu, O.; Atabay, K. Plastic surgeon’s life: Marvelous for mind, exhausting for body. Plast. Reconstr. Surg. 2004, 114, 923–931. [Google Scholar] [CrossRef]
- Rieger, A.; Fenger, S.; Neubert, S.; Weippert, M.; Kreuzfeld, S.; Stoll, R. Psychophysical workload in the operating room: Primary surgeon versus assistant. Surg. Endosc. 2014, 29, 1990–1998. [Google Scholar] [CrossRef]
- Kuhn, E.W.; Choi, Y.-H.; Schönherr, M.; Liakopoulos, O.J.; Rahmanian, P.B.; Choi, C.Y.-U.; Wittwer, T.; Wahlers, T. Intraoperative stress in cardiac surgery: Attendings versus residents. J. Surg. Res. 2013, 182, e43–e49. [Google Scholar] [CrossRef]
- Trockel, M.T.; Menon, N.K.; Rowe, S.G.; Stewart, M.T.; Smith, R.; Lu, M.; Kim, P.K.; Quinn, M.A.; Lawrence, E.; Marchalik, D.; et al. Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors. JAMA Netw. Open 2020, 3, e2028111. [Google Scholar] [CrossRef] [PubMed]
- De Oliveira, R.A.M.; Araújo, L.F.; de Figueiredo, R.C.; Goulart, A.C.; Schmidt, M.I.; Barreto, S.M.; Ribeiro, A.L.P. Coffee Consumption and Heart Rate Variability: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) Cohort Study. Nutrients 2017, 9, 741. [Google Scholar] [CrossRef] [Green Version]
- Garavaglia, L.; Gulich, D.; Defeo, M.M.; Thomas Mailland, J.; Irurzun, I.M. The effect of age on the heart rate variability of healthy subjects. PLoS ONE 2021, 16, e0255894. [Google Scholar] [CrossRef] [PubMed]
- Cagirci, G.; Cay, S.; Karakurt, O.; Eryasar, N.; Kaya, V.; Canga, A.; Yesilay, A.B.; Kilic, H.; Topaloglu, S.; Aras, D.; et al. Influence of heavy cigarette smoking on heart rate variability and heart rate turbulence parameters. Ann. Noninvasive Electrocardiol. 2009, 14, 327–332. [Google Scholar] [CrossRef]
- Dinas, P.C.; Koutedakis, Y.; Flouris, A.D. Effects of active and passive tobacco cigarette smoking on heart rate variability. Int. J. Cardiol. 2013, 163, 109–115. [Google Scholar] [CrossRef] [PubMed]
- Prichard, R.S.; O’Neill, C.J.; Oucharek, J.J.; Holmes, C.Y.V.; Delbridge, L.W.; Sywak, M.S. A prospective study of heart rate variability in endocrine surgery: Surgical training increases consultant’s mental strain. J. Surg. Educ. 2012, 69, 453–458. [Google Scholar] [CrossRef]
- Bergner, T. Burn-out bei Ärzten: Lebensaufgabe statt Lebens-Aufgabe. Mindestens 20 Prozent der Ärzte leiden am Burn-out-Syndrom.Die Entwicklung emotionaler Kompetenz kann davor schützen. Dtsch. Arztebl. 2004, 101, 2232–2234. [Google Scholar]
- Körber, T.; Ismer, B.; Knorre, G.H. von. Die klinische Bedeutung der Verwendung unterschiedlicher Rekordertechnologien für die Ergebnisse der Analyse der Herzfrequenzvariabilität aus dem Langzeit-EKG. Herzschrittmacherther. Elektrophysiol. 2000, 11, 110–116. [Google Scholar] [CrossRef]
- Kunzler, A.M.; Helmreich, I.; Chmitorz, A.; König, J.; Binder, H.; Wessa, M.; Lieb, K. Psychological interventions to foster resilience in healthcare professionals. Cochrane Database Syst. Rev. 2020, 7, CD012527. [Google Scholar] [CrossRef]
- Crewther, B.T.; Shetty, K.; Jarchi, D.; Selvadurai, S.; Cook, C.J.; Leff, D.R.; Darzi, A.; Yang, G.-Z. Skill acquisition and stress adaptations following laparoscopic surgery training and detraining in novice surgeons. Surg. Endosc. 2016, 30, 2961–2968. [Google Scholar] [CrossRef] [PubMed]
- Thielmann, B.; Ackermann, E.; Frommer, J.; Böckelmann, I. Beurteilung eines Stressbewältigungskurses für Studierende. Präv Gesundheitsf 2010, 5, 282–288. [Google Scholar] [CrossRef]
- Thielmann, B.; Schumann, X.; Ackermann, E.; Frommer, J.; Böckelmann, I. Psychophysiologische Untersuchungen zu Studiumsbezogenen Belastungen bei Teilnehmern eines Stressbewältigungskurses für Studenten; 49; Jahrestagung der Deutschen Gesellschaft für Arbeitsmedizin und Umweltmedizin e.V. (DGAUM): Aachen, Germany, 2009; pp. 439–440. [Google Scholar]
HRV Parameters | Explanation | Activity as Part of the Autonomic Nervous System |
---|---|---|
Time domain parameters | ||
Mean HR [1/min] | Heart rate | Sympathetic and parasympathetic nervous system |
Mean RR or NN [ms] | Distance between two R-pins or NN-intervals | No clear assignment |
RMSSD [ms] (Root Mean Square of successive differences) | Square root of the mean of the sum of all squared differences between adjacent RR intervals | Parasympathetic nervous system |
NN50 | Number of consecutive RR intervals that differ from each other by more than 50 ms | Parasympathetic nervous system |
Frequency domain parameters | ||
FFT_LF_po [ms2] | Power density spectrum in the frequency range from 0.04 to 0.15 Hz | Sympathetic and parasympathetic nervous system |
FFT_HF_po [ms2] | Power density spectrum in the frequency range from 0.15 to 0.40 Hz | Parasympathetic nervous system |
FFT LF/HF | Measure of sympatho-vagal balance as quotient of LF and HF | Sympathetic and parasympathetic nervous system |
Stress, PNS, and SNS Index | ||
Stress Index | The stress index is the square root (to make the index normally distributed) of the Baevsky stress index, where values from 150–500 are claimed as the normal range (12.2–22.4 when the square root is applied) | Sympathetic nervous system |
PNS index | Activity of the parasympathetic nervous system described by the mean values of RR, RMSSD, and SD 1(%) | Parasympathetic nervous system |
SNS index | Sympathetic nervous system activity described by mean values of mean HR, stress index, and SD2 (%) | Sympathetic nervous system |
Parameter | Residents | Senior Physicians | p-Value | ||||
---|---|---|---|---|---|---|---|
mv | sd | mv | sd | ||||
Mean RR [ms] | 692.8 | ± | 56.59 | 737.3 | ± | 42.43 | 0.021 |
Mean HR [1/min] | 87.2 | ± | 7.34 | 81.6 | ± | 4.85 | 0.022 |
RMSSD [ms] | 19.5 | ± | 6.42 | 28.1 | ± | 9.69 | 0.008 |
NN50 | 297.67 | ± | 379.03 | 693.40 | ± | 479.68 | 0.018 |
FFT_LF_po [ms2] | 936.41 | ± | 491.49 | 1658.90 | ± | 893.40 | 0.012 |
FFT_HF_po [ms2] | 148.05 | ± | 105.99 | 276.42 | ± | 266.82 | 0.094 |
FFT_LF/HF | 7.2 | ± | 1.76 | 7.2 | ± | 2.84 | 0.974 |
Parameter | Residents | Senior Physicians | p-Value | ||||
---|---|---|---|---|---|---|---|
mv | sd | mv | sd | ||||
PNS Index | −1.76 | ± | 0.32 | −1.32 | ± | 0.45 | 0.004 |
SNS Index | 1.84 | ± | 0.62 | 1.01 | ± | 0.56 | 0.001 |
Stress Index | 11.61 | ± | 2.17 | 8.68 | ± | 1.61 | 0.000 |
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Awad, G.; Pohl, R.; Darius, S.; Thielmann, B.; Kuzmin, B.; Slottosch, I.; Wippermann, J.; Schmidt, H.; Scherner, M.P.; Böckelmann, I. Evaluation of Stress Levels of Trainee Cardiac Surgery Residents during Training Interventions Using Physiological Stress Parameters. Int. J. Environ. Res. Public Health 2021, 18, 11953. https://doi.org/10.3390/ijerph182211953
Awad G, Pohl R, Darius S, Thielmann B, Kuzmin B, Slottosch I, Wippermann J, Schmidt H, Scherner MP, Böckelmann I. Evaluation of Stress Levels of Trainee Cardiac Surgery Residents during Training Interventions Using Physiological Stress Parameters. International Journal of Environmental Research and Public Health. 2021; 18(22):11953. https://doi.org/10.3390/ijerph182211953
Chicago/Turabian StyleAwad, George, Robert Pohl, Sabine Darius, Beatrice Thielmann, Boris Kuzmin, Ingo Slottosch, Jens Wippermann, Hendrik Schmidt, Maximilian Philipp Scherner, and Irina Böckelmann. 2021. "Evaluation of Stress Levels of Trainee Cardiac Surgery Residents during Training Interventions Using Physiological Stress Parameters" International Journal of Environmental Research and Public Health 18, no. 22: 11953. https://doi.org/10.3390/ijerph182211953
APA StyleAwad, G., Pohl, R., Darius, S., Thielmann, B., Kuzmin, B., Slottosch, I., Wippermann, J., Schmidt, H., Scherner, M. P., & Böckelmann, I. (2021). Evaluation of Stress Levels of Trainee Cardiac Surgery Residents during Training Interventions Using Physiological Stress Parameters. International Journal of Environmental Research and Public Health, 18(22), 11953. https://doi.org/10.3390/ijerph182211953