Surgeons' and surgical trainees' acute stress in real operations or simulation: A systematic review
Abstract
Background and purpose Acute stress in surgery is ubiquitous and has an immediate impact on surgical performance and patient safety. Surgeons react with several coping strategies; however, they recognise the necessity of formal stress management training. Thus, stress assessment is a direct need. Surgical simulation is a validated standardised training milieu designed to replicate real-life situations. It replicates stress, prevents biases, and provides objective metrics. The complexity of stress mechanisms makes stress measurement difficult to quantify and interpret. This systematic review aims to identify studies that have used acute stress estimation measurements in surgeons or surgical trainees during real operations or surgical simulation, and to collectively present the rationale of these tools, with special emphasis in salivary markers.Methods A search strategy was implemented to retrieve relevant articles from MEDLINE and SCOPUS databases. The 738 articles retrieved were reviewed for further evaluation according to the predetermined inclusion/exclusion criteria.Results Thirty-three studies were included in this systematic review. The methods for acute stress assessment varied greatly among studies with the non-invasive techniques being the most commonly used. Subjective and objective tests for surgeons' acute stress assessment are being presented.Conclusion There is a broad spectrum of acute mental stress assessment tools in the surgical field and simulation and salivary biomarkers have recently gained popularity. There is a need to maintain a consistent methodology in future research, towards a deeper understanding of acute stress in the surgical field.
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From Wearable sensors for monitoring the physiological and biochemical profile of the athlete (2019) · cites this paper as [87]
Cites
Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & for the PRISMA Group (2009) · BMJ · doi:10.1136/bmj.b2535 · Cited by 83,823 · see citing works
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement.
(2009) · PubMed Central · Cited by 44,859 · see citing works
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gotzsche, P. C., Ioannidis, J. P. A., Clarke, M., Devereaux, P. J., Kleijnen, J., & Moher, D. (2009) · BMJ · doi:10.1136/bmj.b2700 · Cited by 17,648 · see citing works
Marteau, T. M., & Bekker, H. (1992) · British Journal of Clinical Psychology · doi:10.1111/j.2044-8260.1992.tb00997.x · Cited by 3,238 · see citing works
Virtual Reality Training Improves Operating Room Performance
Seymour, N. E., Gallagher, A. G., Roman, S. A., O’Brien, M. K., Bansal, V. K., Andersen, D. K., & Satava, R. M. (2002) · Annals of Surgery · doi:10.1097/00000658-200210000-00008 · Cited by 2,863 · see citing works
Salivary cortisol as a biomarker in stress research
Hellhammer, D. H., Wüst, S., & Kudielka, B. M. (2009) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2008.10.026 · Cited by 1,925 · see citing works
Nater, U. M., & Rohleder, N. (2009) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2009.01.014 · Cited by 1,370 · see citing works
Sex differences in healthy human heart rate variability: A meta-analysis
Koenig, J., & Thayer, J. F. (2016) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2016.03.007 · Cited by 860 · see citing works
Autonomic characteristics of generalized anxiety disorder and worry
Thayer, J. F., Friedman, B. H., & Borkovec, T. D. (1996) · Biological Psychiatry · doi:10.1016/0006-3223(95)00136-0 · Cited by 857 · see citing works
Effects of Work Stress on Ambulatory Blood Pressure, Heart Rate, and Heart Rate Variability
Vrijkotte, T. G. M., van Doornen, L. J. P., & de Geus, E. J. C. (2000) · Hypertension · doi:10.1161/01.hyp.35.4.880 · Cited by 756 · see citing works
van Ravenswaaij‐Arts, C. M. A., Kollee, L. A. A., Hopman, J. C. W., Stoelinga, G. B. A., & van Geijn, H. P. (1993) · Annals of Internal Medicine · doi:10.7326/0003-4819-118-6-199303150-00008 · Cited by 741 · see citing works
Regulation of salivary gland function by autonomic nerves.
Proctor, G., & Carpenter, G. (2007) · Autonomic Neuroscience: Basic & Clinical · doi:10.1016/j.autneu.2006.10.006 · Cited by 723 · see citing works
The impact of stress on surgical performance: A systematic review of the literature
Arora, S., Sevdalis, N., Nestel, D., Woloshynowych, M., Darzi, A. W., & Kneebone, R. L. (2009) · Surgery · doi:10.1016/j.surg.2009.10.007 · Cited by 688 · see citing works
Determinants of salivary α-amylase in humans and methodological considerations
Rohleder, N., & Nater, U. M. (2009) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2008.12.004 · Cited by 604 · see citing works
Classification of factors influencing the use of infrared thermography in humans: A review
Fernández-Cuevas, I., Marins, J. C. B., Lastras, J. A., Carmona, P. M. G., Cano, S. P., García-Concepción, M. Á., & Sillero‐Quintana, M. (2015) · Infrared Physics & Technology · doi:10.1016/j.infrared.2015.02.007 · Cited by 588 · see citing works
Salivary α‐Amylase in Biobehavioral Research: Recent Developments and Applications
GRANGER, D. A., KIVLIGHAN, K. T., El‐SHEIKH, M., GORDIS, E. B., & STROUD, L. R. (2007) · Annals of the New York Academy of Sciences · doi:10.1196/annals.1384.008 · Cited by 572 · see citing works
Effect of psychological stress on the salivary cortisol and amylase levels in healthy young adults
Takai, N., Yamaguchi, M., Aragaki, T., Eto, K., Uchihashi, K., & Nishikawa, Y. (2004) · Archives of Oral Biology · doi:10.1016/j.archoralbio.2004.06.007 · Cited by 568 · cited 1× · see citing works
“acute stress: It seems that sAA responds to stress quicker than sC.(9,99) Additionally, if the concentrations of proteins, such as sAA or sIgA, are to be calculated, the following formula must be used: [protein secretion (U/min) 1⁄4 protein concentration (U/ml) x SFR (ml/min)], with SFR (ml/min) being the sole determi…”
MethodMalamud, D. (2010) · Dental Clinics of North America · doi:10.1016/j.cden.2010.08.004 · Cited by 489 · see citing works
Thermal infrared imaging in psychophysiology: Potentialities and limits
Ioannou, S., Gallese, V., & Merla, A. (2014) · Psychophysiology · doi:10.1111/psyp.12243 · Cited by 367 · see citing works
The effects of psychological stress upon performance.
Lazarus, R. S., Deese, J., & Osler, S. F. (1952) · Psychological Bulletin · doi:10.1037/h0061145 · Cited by 325 · see citing works
Performing laparoscopic surgery is significantly more stressful for the surgeon than open surgery
Berguer, R., Smith, W. D., & Chung, Y.-J. (2001) · Surgical Endoscopy · doi:10.1007/s004640080030 · Cited by 321 · see citing works
Skin temperature reveals the intensity of acute stress
Herborn, K. A., Graves, J. L., Jerem, P., Evans, N. P., Nager, R. G., McCafferty, D. J., & McKeegan, D. E. F. (2015) · Physiology & Behavior · doi:10.1016/j.physbeh.2015.09.032 · Cited by 293 · see citing works
The Trier Social Stress Test protocol for inducing psychological stress.
Birkett, M. (2011) · Journal of Visualized Experiments · doi:10.3791/3238 · Cited by 285 · see citing works
The Proper Role of Nerves in Salivary Secretion: A Review
Garrett, J. R. (1987) · Journal of Dental Research · doi:10.1177/00220345870660020201 · Cited by 277 · see citing works
Bosch, J. A., de Geus, E. J. C., Veerman, E. C. I., Hoogstraten, J., & Amerongen, A. V. N. (2003) · Psychosomatic Medicine · doi:10.1097/01.psy.0000058376.50240.2d · Cited by 249 · see citing works
Salivary Cortisol Levels as a Biological Marker of Stress Reaction
Bozovic, D., Račić, M., & Ivković, N. (2013) · Medical Archives · doi:10.5455/medarh.2013.67.374-377 · Cited by 236 · see citing works
Noto, Y., Sato, T., Kudo, M., Kurata, K., & Hirota, K. (2005) · Anesthesia & Analgesia · doi:10.1213/01.ane.0000184196.60838.8d · Cited by 232 · see citing works
Acute and chronic effects of exercise on markers of mucosal immunity
BISHOP, N. C. (2009) · Frontiers in bioscience · doi:10.2741/3540 · Cited by 227 · see citing works
Making patient safety the focus: Crisis Resource Management in the undergraduate curriculum
Flanagan, B. T., Nestel, D., & Joseph, M. (2004) · Medical Education · doi:10.1111/j.1365-2923.2004.01701.x · Cited by 225 · see citing works
The effect of stress on core and peripheral body temperature in humans
Vinkers, C. H., Penning, R., Hellhammer, J., Verster, J. C., Klaessens, J. H. G. M., Olivier, B., & Kalkman, C. J. (2013) · Stress · doi:10.3109/10253890.2013.807243 · Cited by 220 · see citing works
The Effects of Stress and Coping on Surgical Performance During Simulations
Wetzel, C. M., Black, S. A., Hanna, G. B., Athanasiou, T., Kneebone, R. L., Nestel, D., Wolfe, J. H. N., & Woloshynowych, M. (2009) · Annals of Surgery · doi:10.1097/sla.0b013e3181b3b2be · Cited by 208 · see citing works
Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations
Harvey, A. M., Nathens, A. B., Bandiera, G. W., & LeBlanc, V. R. (2010) · Medical Education · doi:10.1111/j.1365-2923.2010.03634.x · Cited by 199 · see citing works
Comparison of Biomarkers in Blood and Saliva in Healthy Adults
Williamson, S., Munro, C., Pickler, R., Grap, M. J., & Elswick, R. K. (2012) · Nursing Research and Practice · doi:10.1155/2012/246178 · Cited by 197 · see citing works
Impact of stress on resident performance in simulated trauma scenarios
Harvey, A. M., Bandiera, G. W., Nathens, A. B., & LeBlanc, V. R. (2011) · The Journal of Trauma: Injury, Infection, and Critical Care · doi:10.1097/ta.0b013e31821f84be · Cited by 194 · see citing works
Steroid analysis in saliva: an overview.
Lewis, J. G. (2006) · PubMed Central · Cited by 172 · see citing works
Stress impairs psychomotor performance in novice laparoscopic surgeons
Arora, S., Sevdalis, N., Aggarwal, R. K., Sirimanna, P., Darzi, A. W., & Kneebone, R. L. (2010) · Surgical Endoscopy · doi:10.1007/s00464-010-1013-2 · Cited by 170 · see citing works
Managing intraoperative stress: what do surgeons want from a crisis training program?
Arora, S., Sevdalis, N., Nestel, D., Tierney, T., Woloshynowych, M., & Kneebone, R. L. (2009) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2008.02.009 · Cited by 168 · see citing works
Cortisol Responses to Mental Stress and Incident Hypertension in Healthy Men and Women
Hamer, M., & Steptoe, A. (2011) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2011-2132 · Cited by 164 · see citing works
Berguer, R., & Smith, W. (2005) · Journal of Surgical Research · doi:10.1016/j.jss.2005.10.003 · Cited by 160 · see citing works
Saliva as a non-invasive diagnostic tool for inflammation and insulin-resistance
Desai, G. S. (2014) · World Journal of Diabetes · doi:10.4239/wjd.v5.i6.730 · Cited by 158 · see citing works
Exploring the Use of Thermal Infrared Imaging in Human Stress Research
Engert, V., Merla, A., Grant, J. A., Cardone, D., Tusche, A., & Singer, T. (2014) · PLoS ONE · doi:10.1371/journal.pone.0090782 · Cited by 155 · see citing works
Effects of intraoperative breaks on mental and somatic operator fatigue: a randomized clinical trial
Engelmann, C., Schneider, M., Kirschbaum, C., Grote, G., Dingemann, J., Schoof, S., & Ure, B. M. (2010) · Surgical Endoscopy · doi:10.1007/s00464-010-1350-1 · Cited by 153 · see citing works
Extraction of Heart Rate Variability from Smartphone Photoplethysmograms
Peng, R., Zhou, X.-L., Lin, W.-H., & Zhang, Y. (2015) · Computational and Mathematical Methods in Medicine · doi:10.1155/2015/516826 · Cited by 152 · see citing works
Uncini, A., Pullman, S. L., Lovelace, R. E., & Gambi, D. (1988) · Journal of the Neurological Sciences · doi:10.1016/0022-510x(88)90254-7 · Cited by 145 · see citing works
Stress Management Training for Surgeons—A Randomized, Controlled, Intervention Study
Wetzel, C. M., George, A., Hanna, G. B., Athanasiou, T., Black, S. A., Kneebone, R. L., Nestel, D., & Woloshynowych, M. (2011) · Annals of Surgery · doi:10.1097/sla.0b013e318209a594 · Cited by 145 · see citing works
Fernandes, A. D. A., Amorim, P. R. D. S., Brito, C. J., de Moura, A. G., Moreira, D. G., Costa, C. M. A., Sillero‐Quintana, M., & Marins, J. C. B. (2014) · Physiological Measurement · doi:10.1088/0967-3334/35/2/189 · Cited by 145 · see citing works
Mental Practice: Effective Stress Management Training for Novice Surgeons
Arora, S., Aggarwal, R., Moran, A., Sirimanna, P., Crochet, P., Darzi, A., Kneebone, R., & Sevdalis, N. (2011) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2010.09.025 · Cited by 140 · see citing works
Müller, M. P., Hänsel, M., Fichtner, A., Hardt, F., Weber, S., Kirschbaum, C., Rüder, S., Walcher, F., Koch, T., & Eich, C. B. (2009) · Resuscitation · doi:10.1016/j.resuscitation.2009.04.027 · Cited by 139 · see citing works
Arora, S., Tierney, T., Sevdalis, N., Aggarwal, R. K., Nestel, D., Woloshynowych, M., Darzi, A. W., & Kneebone, R. L. (2010) · World Journal of Surgery · doi:10.1007/s00268-010-0559-4 · Cited by 128 · see citing works
Salivary mental stress proteins
Obayashi, K. (2013) · Clinica Chimica Acta · doi:10.1016/j.cca.2013.07.028 · Cited by 125 · see citing works
Hassan, I., Weyers, P., Maschuw, K., Dick, B., Gerdes, B., Rothmund, Μ., & Zielke, A. (2006) · British journal of surgery · doi:10.1002/bjs.5544 · Cited by 120 · see citing works
Böhm, B. (2001) · Archives of Surgery · doi:10.1001/archsurg.136.3.305 · Cited by 119 · see citing works
Fast by Nature - How Stress Patterns Define Human Experience and Performance in Dexterous Tasks
Pavlidis, I. T., Tsiamyrtzis, P., Shastri, D. J., Wesley, A., Zhou, Y., Lindner, P., Buddharaju, P., Joseph, R., Mandapati, A., Dunkin, B. J., et al. (2012) · Scientific Reports · doi:10.1038/srep00305 · Cited by 110 · see citing works
Heart rate and heart rate variability as indirect markers of surgeons’ intraoperative stress
Rieger, A., Stoll, R., Kreuzfeld, S., Behrens, K., & Weippert, M. (2013) · International Archives of Occupational and Environmental Health · doi:10.1007/s00420-013-0847-z · Cited by 105 · see citing works
What stress coping strategies are surgeons relying upon during surgery?
Anton, N. E., Montero, P. N., Howley, L. D., Brown, C., & Stefanidis, D. (2015) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2015.04.002 · Cited by 102 · see citing works
Jones, K. I., Amawi, F., Bhalla, A., Peacock, O., Williams, J. P., & Lund, J. N. (2014) · Colorectal Disease · doi:10.1111/codi.12844 · Cited by 94 · see citing works
Stress training for the surgical resident
Maher, Z., Milner, R. E., Cripe, J., Gaughan, J., Fish, J. H., & Goldberg, A. J. (2013) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2012.10.007 · Cited by 93 · see citing works
The Use of Saliva Markers in Psychobiology: Mechanisms and Methods
Bosch, J. A. (2014) · Monographs in Oral Science · doi:10.1159/000358864 · Cited by 81 · see citing works
Perinasal Imaging of Physiological Stress and Its Affective Potential
Shastri, D., Papadakis, M., Tsiamyrtzis, P., Bass, B., & Pavlidis, I. (2012) · IEEE Transactions on Affective Computing · doi:10.1109/t-affc.2012.13 · Cited by 78 · see citing works
Examination stress leads to improvements on fundamental technical skills for surgery
LeBlanc, V. R., Woodrow, S. I., Sidhu, R. S., & Dubrowski, A. (2008) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2007.08.059 · Cited by 76 · see citing works
Campisi, J., Bravo, Y., Cole, J., & Gobeil, K. (2012) · Physiology & Behavior · doi:10.1016/j.physbeh.2012.09.003 · Cited by 74 · see citing works
Marrelli, M., Gentile, S., Palmieri, F., Paduano, F., & Tatullo, M. (2014) · PLoS ONE · doi:10.1371/journal.pone.0112444 · Cited by 72 · see citing works
Heemskerk, J., Zandbergen, H. R., Keet, S. W. M., Martijnse, I. S., Montfort, G. V., Peters, R. J. A., Svircevic, V., Bouwman, R. A., Baeten, C. G. M. I., & Bouvy, N. D. (2014) · Digestive Surgery · doi:10.1159/000365580 · Cited by 68 · see citing works
Schuetz, M., Gockel, I., Beardi, J., Hakman, P., Dünschede, F., Mönk, S., Heinrichs, W., & Junginger, T. (2007) · Surgical Endoscopy · doi:10.1007/s00464-007-9605-1 · Cited by 64 · see citing works
Optimizing the operating theatre environment
Wong, S. W., Smith, R. E. T., & Crowe, P. J. (2010) · ANZ Journal of Surgery · doi:10.1111/j.1445-2197.2010.05526.x · Cited by 64 · see citing works
Christensen, J., Væth, M., & Wenzel, A. (2012) · Dentomaxillofacial Radiology · doi:10.1259/dmfr/55922484 · Cited by 63 · see citing works
Sweating on the palm and sole: physiological and clinical relevance
Asahina, M., Poudel, A., & Hirano, S. (2015) · Clinical Autonomic Research · doi:10.1007/s10286-015-0282-1 · Cited by 63 · see citing works
Salivary Cortisol, Salivary Alpha Amylase, and the Dental Anxiety Scale
Sadi, H., Finkelman, M., & ROSENBERG, M. B. (2013) · Anesthesia Progress · doi:10.2344/0003-3006-60.2.46 · Cited by 63 · see citing works
Psychobiological stress response to a simulated school shooting in police officers
Strahler, J., & Ziegert, T. (2014) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2014.09.016 · Cited by 61 · see citing works
Stress among surgical attending physicians and trainees
Joseph, B. A., Parvaneh, S., Swartz, T., Haider, A. A., Hassan, A. N., Kulvatunyou, N., Tang, A. L., Latifi, R., Najafi, B., & Rhee, P. (2016) · The Journal of Trauma: Injury, Infection, and Critical Care · doi:10.1097/ta.0000000000001162 · Cited by 60 · see citing works
The Trier Social Stress Test Protocol for Inducing Psychological Stress
Birkett, M. (2011) · Journal of Visualized Experiments · doi:10.3791/3238-v · Cited by 60 · see citing works
Thermal Infrared Imaging-Based Computational Psychophysiology for Psychometrics
Cardone, D., Pinti, P., & Merla, A. (2015) · Computational and Mathematical Methods in Medicine · doi:10.1155/2015/984353 · Cited by 55 · see citing works
Rahim, M. A. A., Rahim, Z. H. A., Ahmad, W. A. W., & Hashim, O. H. (2015) · International Journal of Medical Sciences · doi:10.7150/ijms.11280 · Cited by 55 · see citing works
Psychological and Physical Stress in Surgeons Operating in a Standard or Modern Operating Room
Klein, M. F., Andersen, L. P. H., Alamili, M., Gögenür, I., & Rosenberg, J. (2010) · Surgical Laparoscopy Endoscopy & Percutaneous Techniques · doi:10.1097/sle.0b013e3181ed851d · Cited by 48 · see citing works
Song, M.-H., Tokuda, Y., Nakayama, T., Sato, M., & Hattori, K. (2009) · Interactive Cardiovascular and Thoracic Surgery · doi:10.1510/icvts.2008.195941 · Cited by 47 · see citing works
Plastic Surgeon???s Life: Marvelous for Mind, Exhausting for Body
Demirtaş, Y., Tulmaç, M., Yavuzer, R., Yalcin, R., Ayhan, S., Latıfoǧlu, O., & Atabay, K. (2004) · Plastic & Reconstructive Surgery · doi:10.1097/01.prs.0000133166.50279.7c · Cited by 46 · see citing works
Professional stress in anesthesiology: a review
Gurman, G. M., Klein, M., & Weksler, N. (2011) · Journal of Clinical Monitoring and Computing · doi:10.1007/s10877-011-9328-7 · Cited by 46 · see citing works
The surgeon's mental load during decision making at various stages of operations
Czyżewska, E., Kiczka, K., Czarnecki, A., & Pokinko, P. (1983) · European Journal of Applied Physiology · doi:10.1007/bf00429080 · Cited by 43 · see citing works
McGraw, L. K., Out, D., Hammermeister, J., Ohlson, C., Pickering, M. A., & Granger, D. A. (2012) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2012.05.009 · Cited by 42 · see citing works
Burnout syndrome in oral and maxillofacial surgeons: a critical analysis
Porto, G. G., Carneiro, S. C. D. S., Vasconcelos, B. C. D. E., Nascimento, M. M., & Leal, J.-L. (2014) · International Journal of Oral and Maxillofacial Surgery · doi:10.1016/j.ijom.2013.10.025 · Cited by 39 · see citing works
The effect of skin thermistor fixation method on weighted mean skin temperature
Tyler, C. J. (2011) · Physiological Measurement · doi:10.1088/0967-3334/32/10/003 · Cited by 39 · see citing works
Prichard, R. S., O’Neill, C. J., Oucharek, J. J., Colinda, Y. H., Delbridge, L., & Sywak, M. S. (2012) · Journal of surgical education · doi:10.1016/j.jsurg.2012.04.002 · Cited by 35 · see citing works
Psychophysical workload in the operating room: primary surgeon versus assistant
Rieger, A., Fenger, S., Neubert, S., Weippert, M., Kreuzfeld, S., & Stoll, R. (2014) · Surgical Endoscopy · doi:10.1007/s00464-014-3899-6 · Cited by 35 · see citing works
Intake of green tea inhibited increase of salivary chromogranin A after mental task stress loads
Yoto, A., Murao, S., Nakamura, Y., & Yokogoshi, H. (2014) · Journal of Physiological Anthropology · doi:10.1186/1880-6805-33-20 · Cited by 31 · see citing works
James, D. R. C., Orihuela‐Espina, F., Leff, D. R., Sodergren, M. H., Athanasiou, T., Darzi, A. W., & Yang, G. (2011) · Surgery · doi:10.1016/j.surg.2010.11.019 · Cited by 30 · see citing works
Chromogranin A: Novel biomarker between periodontal disease and psychosocial stress
Reshma, A. P., Arunachalam, R., Pillai, J., Kurra, S. B., Varkey, V., & Prince, M. (2013) · Journal of Indian Society of Periodontology · doi:10.4103/0972-124x.113076 · Cited by 29 · see citing works
Heart rates of surgeons in theatre
BECKER, W. G. E., Ellis, H. L., Goldsmith, R. H., & Kaye, A. M. (1983) · Ergonomics · doi:10.1080/00140138308963401 · Cited by 28 · see citing works
Phitayakorn, R., Minehart, R. D., Hemingway, M., Pian-Smith, M. C. M., & PETRUSA, E. R. (2014) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2014.08.036 · Cited by 28 · see citing works
Alobid, I., de Pablo, J., Mullol, J., Centellas, S., Parramón, G., Carrasco, J., Armario, A., & Bernal‐Sprekelsen, M. S. (2011) · Archives of Otolaryngology - Head and Neck Surgery · doi:10.1001/archoto.2011.60 · Cited by 27 · see citing works
Building the Clinical Bridge: An Australian Success
Wallis, M. C., & Chaboyer, W. P. (2012) · Nursing Research and Practice · doi:10.1155/2012/579072 · Cited by 26 · see citing works
Smith, W. D., Berguer, R., & Rosser, J. C. (2003) · PubMed · Cited by 21 · see citing works
Smith, W. D., Yi-Hung, C., & Berguer, R. (2000) · Studies in health technology and informatics · doi:10.3233/978-1-60750-914-1-309 · Cited by 21 · see citing works
Advanced Engineering Technology for Measuring Performance
Rutherford, D. N., D’Angelo, A.-L. D., Law, K. E., & Pugh, C. M. (2015) · Surgical Clinics of North America · doi:10.1016/j.suc.2015.04.005 · Cited by 20 · see citing works
Andersen, L. P. H., Klein, M. F., Gögenür, I., & Rosenberg, J. (2012) · Surgical Laparoscopy Endoscopy & Percutaneous Techniques · doi:10.1097/sle.0b013e3182420acf · Cited by 20 · see citing works
Assessment of psychological tension after premedication by measurement of salivary chromogranin A
Obara, S., & Iwama, H. (2005) · Journal of Clinical Anesthesia · doi:10.1016/j.jclinane.2005.08.001 · Cited by 18 · see citing works
Investigation of Sex Differences In sIgA Response to the Trier Social Stress Test
Birkett, M., Johnson, L., & Gelety, C. (2016) · Stress and Health · doi:10.1002/smi.2680 · Cited by 17 · see citing works
Yamanouchi, K., Hayashida, N., Kuba, S., Sakimura, C., Kuroki, T., Togo, M., Katayama, N., Takamura, N., & Eguchi, S. (2015) · The Tohoku Journal of Experimental Medicine · doi:10.1620/tjem.237.157 · Cited by 15 · see citing works
Evaluation of stress patterns during simulated laparoscopy in residency.
Ghazali, D. A., Faure, J. P., Brèque, C., & Oriot, D. (2016) · PubMed · Cited by 14 · see citing works
Characteristics of Salivary Chromogranin A as a Short-term Mental Stress Biomarker
Nomura, S., Mizuno, T., Nozawa, A., Asano, H., & Ide, H. (2010) · BME · Cited by 14 · see citing works
Pai, D., Ram, S., Madan, S. S., Soe, H. H. K., & Barua, A. (2014) · PubMed · Cited by 11 · see citing works
Ducarme, G., Bricou, A., Chanelles, O., Sifer, C., & Poncelet, C. (2015) · Gynecologic and Obstetric Investigation · doi:10.1159/000376575 · Cited by 8 · see citing works
Validity and reliability of a sensor-enabled intubation trainer: a focus on patient-centered data
Issa, N., Salud, L. H., Kwan, C., Woods, K. B. W., & Pugh, C. M. (2012) · Journal of Surgical Research · doi:10.1016/j.jss.2012.03.047 · Cited by 7 · see citing works
Smith Warren, D., Ramon, B., & Rosser Jr. James, C. (2003) · Studies in Health Technology and Informatics · doi:10.3233/978-1-60750-938-7-318
Flagged first, then by citations
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Georgiou, K., Larentzakis, A. V., Khamis, N. N., Alsuhaibani, G. I., Alaska, Y. A., & Giallafos, E. J. (2018) · Folia Medica · doi:10.2478/folmed-2018-0012 · Cited by 244 · see citing works
Self-citationCollins, J. W., Levy, J. A., Stefanidis, D., Gallagher, A. G., Coleman, M., Cecil, T. D., Ericsson, A. K., Mottrie, A., Wiklund, P. N., Ahmed, K., et al. (2019) · European Urology · doi:10.1016/j.eururo.2018.12.044 · Cited by 106 · see citing works
Naik, R., Kogkas, A., Ashrafian, H., Mylonas, G. P., & Darzi, A. W. (2022) · Journal of Surgical Research · doi:10.1016/j.jss.2022.07.010 · Cited by 40 · see citing works
Torkamani‐Azar, M., Lee, A., & Bednarik, R. (2022) · IEEE Journal of Biomedical and Health Informatics · doi:10.1109/jbhi.2022.3182869 · Cited by 38 · see citing works
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Chandra, G., & Pandey, A. (2021) · Expert Review of Medical Devices · doi:10.1080/17434440.2021.1935875 · Cited by 35 · see citing works
Stress in surgical educational environments: a systematic review
Tjønnås, M. S., Guzmán-García, C., González, P. S., Aguilera, E. J. G., García, I. O., & Våpenstad, C. (2022) · BMC Medical Education · doi:10.1186/s12909-022-03841-6 · Cited by 35 · see citing works
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Kent, J. R., Thornton, M., Fong, A., Hall, E. C., Fitzgibbons, S., & Sava, J. A. (2019) · The Journal of Trauma: Injury, Infection, and Critical Care · doi:10.1097/ta.0000000000002565 · Cited by 31 · see citing works
Howie, E. E., Ambler, O., Gunn, E., DIAS, R. D., Wigmore, S. J., Skipworth, R. J. E., & Yule, S. (2024) · Annals of Surgery · doi:10.1097/sla.0000000000006211 · Cited by 29 · see citing works
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Mayer, Y., Etgar, S., Shiffman, N., & Lurie, I. (2021) · Measurement and Evaluation in Counseling and Development · doi:10.1080/07481756.2021.1998780 · Cited by 30 · see citing works
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Barbadoro, P., Brunzini, A., Dolcini, J., Formenti, L., Luciani, A., Messi, D., Papetti, A., Ponzio, E., Germani, M., Starlab Working Collaborative Group, et al. (2023) · BMC Medical Education · doi:10.1186/s12909-023-04101-x · Cited by 27 · see citing works
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Stecz, P., Makara‐Studzińska, M., Białka, S., & Misiołek, H. (2021) · Scientific Reports · doi:10.1038/s41598-021-96279-7 · Cited by 23 · see citing works
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Huu, P. L., Bellagamba, G., Bouhadfane, M., Villa, A. F., & Lehucher, M.-P. (2022) · International Archives of Occupational and Environmental Health · doi:10.1007/s00420-021-01784-x · Cited by 18 · see citing works
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Suko, Y., SHINDO, T., Saito, K., Takayama, N., Warisawa, S., Sakuma, T., Ito, M., Kytölä, P., Nummi, T., & Korpela, K. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph191912736 · Cited by 12 · see citing works
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Feeley, A. A., Feeley, I. H., McManus, R., Lunn, J. V., Sheehan, E. C., & Merghani, K. (2022) · Journal of surgical education · doi:10.1016/j.jsurg.2022.07.006 · Cited by 7 · see citing works
Mozzati, M., Gallesio, G., Göker, F., Tumedei, M., Paoleschi, C., Tedesco, A. D., & FABBRO, M. D. (2020) · Journal of Oral Implantology · doi:10.1563/aaid-joi-d-19-00195 · Cited by 7 · see citing works
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Lee, A., Torkamani‐Azar, M., Zheng, B., & Bednarik, R. (2023) · Journal of Multidisciplinary Healthcare · doi:10.2147/jmdh.s401325 · Cited by 6 · see citing works
Kambakamba, P., Naiem, A., Betz, E., Hotz, A. S., Richetti, K., Stein, M., Abry, L., Meier, A., Seeger, N., Grochola, L. F., et al. (2024) · Langenbeck s Archives of Surgery · doi:10.1007/s00423-024-03287-y · Cited by 6 · see citing works
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Blalock, A. E., Noble, C. E., Chinchilla, J. P., Flores, A., & Lepe, P. R. (2021) · New Directions for Student Services · doi:10.1002/ss.20407 · Cited by 5 · see citing works
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Niwa, K., TSUMUGIWA, T., & YOKOGAWA, R. (2024) · IEEE Access · doi:10.1109/access.2024.3445158 · Cited by 2 · see citing works
Angus, A. A., Howard, K. K., Jawanda, H. S., Callahan, R. E., Ziegler, K. M., & Roach, V. A. (2022) · Surgery · doi:10.1016/j.surg.2022.07.010 · Cited by 2 · see citing works
Georgiou, K. E., Boyanov, N. B., Thanasas, D., Sandblom, G., Linardoutsos, D., & Enochsson, L. (2024) · Frontiers in Surgery · doi:10.3389/fsurg.2024.1364195 · Cited by 2 · see citing works
Self-citationNorton, J., Boyle, C., Kerray, F. M., Tambyraja, A. L., & Yule, S. (2024) · Journal of Surgical Protocols and Research Methodologies · doi:10.1093/jsprm/snae015 · Cited by 2 · see citing works
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Turliuc, D. M., Costea, C. F., Turliuc, Ș., Sascău, R. A., Pătrășcanu, E., Poeată, I., & Cucu, A. I. (2018) · Romanian Neurosurgery · doi:10.2478/romneu-2018-0027 · Cited by 1 · see citing works
Solari, F., Barlow, E., Egan, R. J., Lewis, W. G., & Carpenter, C. (2025) · Injury · doi:10.1016/j.injury.2025.112184 · Cited by 1 · see citing works
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Barlow, E., Robinson, D. B. T., James, O. P., Luton, O., Eley, C. L., Bowman, C. R., Kearns, M., Powell, A. G. M. T., Hanratty, D., Barry, J. D., et al. (2025) · Journal of surgical education · doi:10.1016/j.jsurg.2025.103549 · Cited by 1 · see citing works
Wilkinson, A., Patel, R. R., Darzi, A. W., Singh, H., & Leff, D. R. (2021) · Elsevier eBooks · doi:10.1016/b978-0-12-821413-8.00013-0
Tewfik, G., Naftalovich, R., Rodriguez-Aponte, C., & Ezzat, B. (2023) · Interactive Journal of Medical Research · doi:10.2196/42060
Non-invasive stress estimation in simulative endoscopy setting: literature review.
Boyanov, N., & Andonov, V. (2024) · Folia Medica · doi:10.3897/folmed.66.e115645
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Sydorenko, A. Y., & Spindler, H. (2024) · Cardiology in the Young · doi:10.1017/s1047951124025198
Norton, J., Geraghty, A., Howie, E. E., Boyle, C., Yule, S., & Tambyraja, A. L. (2024) · Journal of Surgical Protocols and Research Methodologies · doi:10.1093/jsprm/snae016
Tjønnås, M. S., Muller, S., Våpenstad, C., Tjønnås, J., Ose, S. O., Das, A., & Sandsund, M. (2024) · Figshare · doi:10.6084/m9.figshare.25596536
Tjønnås, M. S., Muller, S., Våpenstad, C., Tjønnås, J., Ose, S. O., Das, A., & Sandsund, M. (2024) · Figshare · doi:10.6084/m9.figshare.25596494
Tjønnås, M. S., Muller, S., Våpenstad, C., Tjønnås, J., Ose, S. O., Das, A., & Sandsund, M. (2024) · Figshare · doi:10.6084/m9.figshare.26705631
Tjønnås, M. S., Muller, S., Våpenstad, C., Tjønnås, J., Ose, S. O., Das, A., & Sandsund, M. (2024) · Figshare · doi:10.6084/m9.figshare.26705634
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Martin, G. C., Huaulmé, A., Cavaillé, M., Cruz-Panesso, I., de Lamirande, J. L., Trottier, S., Kyrillos, R., Hardy, I., Jannin, P., Tanoubi, I., et al. (2026) · Canadian Journal of Ophthalmology · doi:10.1016/j.jcjo.2026.03.002
Beyrouti, R. C., López-García, M., Quesada, M. E. T., Ferré, J. F., Campos‐Mollo, E., Alfayate-Guerra, R., & Aracil‐Marco, A. (2026) · PLoS ONE · doi:10.1371/journal.pone.0354245
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Hayashi, S., Watanabe, J., Hayashi, K., Matsui, R., Kinoshita, J., & Inaki, N. (2026) · Surgical Endoscopy · doi:10.1007/s00464-026-13224-3
Gigli, S., del Torchio, S., & Castiglioni, B. (2026) · Global Clinical Engineering Journal · doi:10.31354/globalce.v8i3.415
Pasten, A., Ripoll, R., Domènech, A., & Krauel, L. (2026) · Journal of Pediatric Surgery · doi:10.1016/j.jpedsurg.2026.163530
- Authors
- Georgiou, K., Larentzakis, A., & Papavassiliou, A. G.
- Affiliations
- National and Kapodistrian University of Athens (GR)
- Corresponding author
- Larentzakis, Andreas
- Venue
- The Surgeon
- Publisher
- Elsevier BV
- Published
- 2017-12
- Volume
- 15
- Issue
- 6
- Pages
- 355-365
- ISSN
- 1479-666X (ISSN-L)
- OpenAlex
- W2734399071
- Cited by
- 69
- References
- 101
- Citations by year
- 2026: 5 · 2025: 4 · 2024: 17 · 2023: 7 · 2022: 10 · 2021: 10 · 2020: 8 · 2019: 6 · 2018: 2
- FWCI
- 0.93
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Surgeon (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Surgical Simulation and Training
- Health Sciences › Medicine › Physiology › Simulation-Based Education in Healthcare
- Health Sciences › Health Professions › General Health Professions › Healthcare professionals’ stress and burnout
- Keywords
- acute stress, surgeons, surgical residents, surgical simulation, salivary biomarkers, stress measurement, stress management, surgical performance, patient safety, coping strategies
- MeSH terms
- Simulation Training, Workforce, Acute Disease, Clinical Competence, Education, Medical, Graduate, Humans, Stress, Psychological, General Surgery, Surgical Procedures, Operative, Training Support, Surgeons
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