Effects of psychological problems on surgical outcomes

patient’s and the health care provider’s viewpoint. Psychological problems may affect up to 20% of the population, with almost half of them non-treated. Surgeons have to deal with a significant number of patients with psychological problems, which affect surgical outcomes changing how symptoms, results and side effects are interpreted. Surgeons also face psychological problems at a significant rate. Although there are no studies on the effect of chronic psychological problems of the surgeon on outcomes, in simulated scenarios, acute stress usually leads to worse performance. Some initiatives can be implemented to improve outcomes based on the effect of psychological problems.


INTRODUCTION
Surgeons are becoming aware that surgical outcomes are not only based on technical skills. Thus, current surgical literature is open to multidisciplinarity, perioperative care, analysis of surgical team cognition and non-technical skills, among others. The impact of psychological problems on outcomes is also noteworthy from both the patient's and the health care provider's viewpoint.

Effects of psychological problems on surgical outcomes -Patients
The first question to be answered is how many of our patients have psychological problems. A survey in a large metropolitan area showed a prevalence of minor psychiatric disorders (anxiety/depression) in 20% of the population 1 . This figure varies according to geographic location, age, and socioeconomic status, but remains close to the 15 to 20% rate 2-4 . Moreover, a significant number of individuals have a non-diagnosed or non-treated status. In the US, the prevalence of mental disorder was 18% in 2016, but only 43% received some treatment, according to the National Institute of Mental Health. Thus, surgeons have to deal with a significant number of patients with psychological problems.
The second question is how the patient's psychological problems affect surgical outcomes. First, they change how symptoms are interpreted. Psy-

SUMMARY
Surgeons are becoming aware that surgical outcomes are not only based on technical skills. The impact of psychological problems on outcomes must be studied from both the patient's and the health care provider's viewpoint. Psychological problems may affect up to 20% of the population, with almost half of them non-treated. Surgeons have to deal with a significant number of patients with psychological problems, which affect surgical outcomes changing how symptoms, results and side effects are interpreted. Surgeons also face psychological problems at a significant rate. Although there are no studies on the effect of chronic psychological problems of the surgeon on outcomes, in simulated scenarios, acute stress usually leads to worse performance. Some initiatives can be implemented to improve outcomes based on the effect of psychological problems.
KEYWORDS: surgery; treatment outcome; mental disorders; burnout, professional chological problems may lead to hypersensitivity and hypervigilance. These two conditions may be part of the clinical presentation of the psychological problem, but there is also a molecular relationship between mental disorders and pain modulation 5 . Second, they affect the way results are interpreted. Patients may suffer from the nocebo phenomenon, defined as when a patient experiences adverse side-effects that are not a direct result of the proposed treatment 6 . Side effects, even irrelevant symptoms, of operation may be disastrous, and persistent unrelated symptoms may prevent expectations from being fulfilled.
The deterioration of surgical outcomes due to psychological problems has been studied in functional surgical diseases such as gastroesophageal reflux disease (GERD). Velanovich et al. 7 showed a decrease in satisfactory outcomes after a fundoplication from 95% to 11% in the presence of a psychiatric disorder. Outside the functional disorders in which a psychological problem could intuitively have more influence, psychological status also plays a role in the recovery from different types of operations in terms of pain perception, return to work, and quality of life 8 . Psychological problems seem to be detrimental even to oncological survival 9 .
Effects of psychological problems on surgical outcomes -Surgeons If we ask the same question as we did for patients, of how many surgeons have psychological problems, the first thing that comes to most of our minds is the estimate that surgeons are the 5th career with the highest proportion of psychopaths 10 . Is this caused by a peculiar "surgical personality" or surgeons do have psychological problems in a higher proportion? The surgical personality does seem to exist. Surgeons have higher levels of conscientiousness, agreeableness, openness, and neuroticism than non-surgeons 11 . Surgeons, however, are prone to psychological problems as well. Minor psychiatric disorders are diagnosed on 16-37% of surgeons 12 . Burnout is a serious problem that has been extensively studied. It is "a syndrome of emotional exhaustion and cynicism that occurs frequently among individuals who do people work of some kind" 13 . Burnout among surgeons is increasing in incidence, with a rate of 53% in 2014 13 . The scenario keeps getting worse. Alcoholism among surgeons reaches 15% 14 , and suicidal ideation ranges from 6% in the US to 18% in Italy 15, 16 .
In regards to the second question, whether surgeons' psychological problems affect surgical outcomes is still debatable. Acute stress and stressors, such as sleep deprivation, certainly affect technical performance 17 . To the best of our knowledge, there are no dedicated studies on chronic psychological problems and surgical outcomes. Several studies, however, show that surgeons are profoundly affected by errors 18 .
A third question arises when one inquiry if it is possible to select better psychologically prepared surgeons. We asked past and present surgical residents in regards to attitudes, experiences during training, and professional expectations to find less professional satisfaction among the present residents 19,20 . The decreased satisfaction with work, which is characteristic of the generation Y 21 , may increase the level of burnout and probably of minor psychiatric disorders. Unfortunately, a good tool to select successful surgical residents is not yet available 22 .

PREVENTION
Some initiatives could improve outcomes based on the effect of psychological problems (Figure 1).
In regards to the patient's psychological problems, the use of scores or questionnaires to diagnose psychological problems is restricted by limitations of the available tools and ethical aspects. Nevertheless, long conversations are necessary to understand the expectations of patients concerning outcomes and to express possible side effects. Patients must be carefully selected for adequate procedures. Finally, multidisciplinary care is essential since surgeons usually are not good for handling patients with psychological problems.
From the surgeons' perspective, they must take good care of their wellness, search for mentors 13 , and learn how to deal with errors and adversities. In es- sence, they can do what they like but also need to like what they have to do and be resilient. Curiously, resilience was the theme of 3 presidential addresses from 3 different surgical societies 23-25 . In all 3, resilience was claimed as a desirable characteristic to excel in surgery.

Conflict-of-interest statement
There are no conflicts of interest to report. Conference at the International Session "Non-technical skills for gastrointestinal surgeons" at the SSAT Annual Meeting, Washington, DC, June 2018.