Performance anxiety: implications for obstetricians and gynaecologists

Articles in the Tips and Techniques section are personal views from experts in their field on how to carry out procedures in obstetrics and gynaecology. Performance anxiety refers to the interrelationship between anxiety, or arousal level, and performance under stressful circumstances. While performance anxiety is well documented in the fields of sports, music and the performing arts, it has been rarely studied in medicine. Although it has been considered in trauma and orthopaedics,1 and general surgery,2 performance anxiety has yet to be examined specifically in obstetrics and gynaecology (O&G). O&G is renowned to be a challenging speciality to work in. This is exemplified by the fact that more than 30% of doctors leave the speciality before completion of training.3 Furthermore, following the COVID-19 pandemic, there has been significant additional professional anxiety as a direct consequence of treating women infected with the virus, and the emergence of associated rota gaps, service provision concerns, bed crises and economic instability have added additional pressure on healthcare workers.4 As such, now is the time to consider the potential impact of these anxieties, and specifically how they may impact performance and well-being. While acknowledging that stress and anxiety are normal responses to the emotive and acute environment within which the O&G works, the aim of this manuscript is to summarise the main cognitive–behavioural theories underpinning performance anxiety and contextualise the importance within O&G. It will also outline strategies that clinicians can utilise to adapt their responses to stress, therefore enhancing professional performance, optimising well-being and ultimately improving clinical care and patient safety. Apprehensive feelings, or the feelings of foreboding triggered by the performance context, and the defence mechanisms employed to cope with those feelings, are complex. Performance in response to prevailing anxiety in challenging circumstances embodies the interplay between physiology, cognition and behaviour. The physiological symptoms of arousal are mediated through the release of adrenaline and cortisol by the sympathetic nervous system. Adrenaline increases heart rate, blood pressure, respiratory rate, sweating and muscle tension.5 A small amount brings excitement, and larger amounts give rise to anxiety and irritability. The impact of this increase in physiological arousal on performance is best described by the Yerkes–Dodson law,6 which presents the relationship as an inverted-U curve (Figure 1). Simplistically, performance improves as physiological arousal increases until an optimum point, after which over-arousal results in deterioration in performance. The effects of prolonged stress on the curve have also been described; there is a reduction in the level of stress at which optimal performance is achieved, and the peak of the curve shifts to the left. Moreover, the height of the peak might also decrease, indicating that even at optimal stress levels, performance is lower than it would be under short-term stress conditions, and prolonged stress can cause the curve to flatten, indicating a reduced difference in performance between low and high levels of stress. Ultimately, an overall decline in performance across all levels of arousal is observed with chronic stress, leading to issues like burnout, fatigue and decreased cognitive function.7 The cognitive manifestations of anxiety can be broadly divided into two categories: worry and self-focus.8 Anxiety, driven by worry and self-focus, directs attention towards perceived threatening stimuli, such as a poor surgical outcome or the negative judgement of colleagues, and may even reduce or divert attention from the intended results, for example competently performing surgery or achieving the optimal birth outcome. This undesired diversion of attention away from the task at hand can subsequently negatively impact performance. Alongside worry and self-focus, another cognitive component of performance anxiety has been proposed—the ‘regulatory dimension’—which describes the performer's self-perception of their ability to cope and maintain control when performing a task under stressful conditions.8 Performance is therefore influenced by both physiological and cognitive arousal, a notion that prompted Hardy and Fazey to conceive the catastrophe theory.9 This theory posits that the Yerkes–Dodson law is applicable in circumstances when an individual is experiencing a relatively low level of worry about performance. Conversely, if there is already a high level of worry or physiological arousal, once the point of optimal arousal has been reached or there is an increase in worry, there may subsequently be a steep, catastrophic deterioration in performance. This theory demonstrates the interdependent relationship between physiological arousal and cognition, illustrating how a modest level of worry can increase arousal and therefore improve performance; however, if physiological arousal is already heightened, this can precipitate high levels of worry, resulting in impaired performance. Skill establishment is the most widely documented behaviour in the literature relating to performance anxiety and is essentially an increase in the automaticity of movement due to practice.10 While not studied in the specific context of performance anxiety in O&G, movement automaticity is reinforced, for example with the use of box-trainers for laparoscopic skills. Laparoscopic simulation has been shown to increase the surgical proficiency of trainees through practice.11 and the associated increased automaticity of movement would likely reduce surgical performance anxiety, especially in emergency situations when there may be additional pressures. Other behaviours such as rituals, or pre-performance routines, are widely practised in sports to reduce performance anxiety. The performer will often carry the belief that these behaviours have a specific purpose, or even power, to influence or better their performance.12 While a tennis player may bounce the ball a fixed number of times before hitting a serve, in O&G, a surgeon's choice of music in theatre may contribute to the pre-performance routine. A study of the effects of preferred music on simulated laparoscopic surgical performance among novices found that instrument handling was significantly improved, and skills tasks were performed quicker, suggesting that this behaviour could lead to a reduced mental workload and enhanced surgical performance.13 The presence of rituals across many different performance contexts would suggest that they are critical to self-regulation and goal attainment, and may be a useful tool to explore as a coping strategy for performance anxiety within O&G. Performance anxiety is recognised in sports, although in sports there is a pre-defined time during which the athlete is required to perform, unlike in O&G wherein particularly ‘on-call’, the obstetrician and gynaecologist is exposed to performance anxiety for prolonged and sometimes undefined periods of time under unpredictable circumstances. Therefore, it may be concluded that more research into performance anxiety specifically in the context of the speciality might be beneficial in order to develop tailored coping strategies. Achieving near-perfection is generally a pre-requisite to being a distinguished performer, albeit perfectionism appears to be associated with increased levels of anxiety. A meta-analysis examining the effects of anxiety on sports performance found a significant association between increased levels of anxiety upon performance. The study also demonstrated that the effect of anxiety on performance was more pronounced when considering high-standard athletes versus low-standard athletes, attributing this to performing under increased pressure.14 Although likely to be a beneficial trait in O&G, the conundrum of perfectionism is such that while it may be positively motivational and improve performance, if maladaptive, the resultant increased levels of stress could detrimentally affect performance and well-being.15 This could be a contributory factor to and an indicator for those at increased risk of performance anxiety. Impostor syndrome (IS) describes the phenomenon whereby high-achieving individuals feel they do not deserve their success and fail to internalise their achievements, with a persistent self-doubt and fear of being exposed as a fraud or an impostor, despite objective evidence of their accomplishments.16 Individuals with IS incorrectly attribute their success to external factors yet internalise their failures, thus perpetuating the cycle (Figure 2). A recent systematic review demonstrated the high prevalence of IS among healthcare professionals, including clinicians, and its negative impact on job performance and association with burnout.17 Burnout has been described as a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job, and has been described as having three key dimensions: overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment.18 Recognition of anxiety and its effects on performance within healthcare is poor among clinicians. Since the start of the COVID-19 pandemic, there has been increased reporting and awareness of anxiety and depression. A study investigating the prevalence of mental health disorders among obstetricians and gynaecologists found a significantly higher prevalence of symptoms of depression and anxiety compared with the general population. The authors also reported that less than half of the respondents felt that they were able to talk to their colleagues about their mental health, with fear of discrimination being a barrier to physicians seeking psychological interventions.19 ‘State anxiety’ reflects the psychological and physiological transient reactions directly related to adverse situations in a given moment, whereas ‘trait anxiety’ refers to a personality trait and is often considered a characteristic that stays relatively stable over time. More specifically, Spielberger et al. described this as ‘differences between people in the tendency to perceive stressful situations as dangerous or threatening and to respond to such situations with elevations in the intensity of their state anxiety reactions’.20 One of the key attributes of working within O&G is the varied workload, and a training programme that necessitates exposure to a wide-ranging variety of clinical settings. This variety within O&G is often considered a positive aspect by those choosing to pursue a career in the speciality, providing the opportunity to develop and practise a diversity of skills across multiple areas of differing levels of stimulation. This mix of pace demonstrates that obstetricians and gynaecologists must be able to adapt fluidly to differing levels of arousal and anxiety, as demonstrated in Figure 3. Personality plays a vital role in any career choice, and this remains particularly relevant when choosing a speciality within the medical profession. The broad variety in workload and pace within O&G poses a dilemma when considering the crucial significance of personality and its influence on career choice, performance and well-being. For some individuals, increased levels of arousal, for example working in high-pressure environments such as a labour ward, can lead to significant anxiety and distress, with an associated detrimental effect on performance and well-being; while for others the same level of heightened arousal may boost performance, welfare and career satisfaction. Conversely, other individuals may reach their optimal level of arousal and achieve peak performance in lesser-arousing environments such as the outpatient clinic, while for others this reduced level of arousal and diminished stimulation may result in indifference and suboptimal performance. Research also indicates that narcissistic personality traits are observed within O&G, impacting both practitioners and their work environment. Narcissistic personalities can often exhibit strengths such as charisma and confidence, which can be beneficial in leadership roles. However, these traits can also have detrimental effects, such as manipulation, lack of empathy and an exaggerated sense of entitlement, which can disrupt team dynamics and patient care, and result in poor mentorship.21 A recent survey of >3000 UK-based doctors working within O&G identified that more than a third met the criteria for burnout.21 Those who met the criteria for burnout were more likely to practice defensively and had higher rates of depression and anxiety, highlighting the potential resultant clinical and psychological sequelae. Experience appears to be inversely related to burnout, with 43% of trainees meeting the criteria versus 31% of consultants.22 Figure 4 presents a schematic representation of the relationship between experience, arousal and performance in the specific context of O&G. It is widely documented that common mental health problems are more prevalent among women compared with men, including anxiety, depression, obsessive-compulsive disorder and panic disorder.23 Although performance anxiety is experienced by both genders, higher rates of performance anxiety in women have been reported in sports,24 and in trauma and orthopaedics trainees in the United Kingdom.1 Given that three-quarters of O&G trainees in the United Kingdom are female,25 it is imperative that performance anxiety specifically within O&G is considered and care taken to mitigate its negative effects. In the medical profession, research into stress management has largely focused on managing intraoperative stress; however, there has been little research into specific interventions to reduce performance anxiety. As such, it is necessary to cross-fertilise between disciplines where performance anxiety has been more actively considered, such as in musicians. A study of symphony and opera musicians reported that 24% of musicians frequently suffered stage fright, which is considered the most severe form of performance anxiety in this context, while 13% suffered acute anxiety.26 Proposed therapies for performance anxiety in musicians include cognitive behavioural therapy (CBT), hypnotherapy and the use of beta-blockers.27 A systematic review found that CBT was the most commonly studied intervention, and around half of the studies demonstrated a reduction in performance anxiety with CBT.28 As such, CBT should be considered in trainees who experience significant performance anxiety that is impacting their performance and patient care. A number of other interventions have been proposed for targeting performance anxiety and burnout, the majority of which are individual-focused, including health-promoting behaviours such as exercise, healthy nutrition and mindfulness.29 Moreover, embracing coping strategies such as positive reinterpretation and growth by conceptualising the stressor in a positive way, planning and active coping by taking action to deal with the stressor have also been proposed.30, 31 Socially supported coping strategies that have been documented include focus on and venting of emotions and social support.30 Interestingly, a recent systematic review of interventions to reduce doctor burnout reported organisation-directed interventions such as group sessions to promote teamwork, altered shift patterns and workload reduction had a more pronounced effect on reducing burnout compared to solely individual strategies,32 emphasising the need for implementing effective organisational strategies. Personality questionnaires, such as the Myers–Briggs test, are used in many industries when vetting new employees and facilitate recruitment decision-making. The questionnaires also provide the participant with insight into their personality traits and how these may influence behaviour, thereby allowing them to understand their strengths and areas for improvement. This empowers individuals to make more informed and constructive career choices and decisions. A Finnish study examining the role of personality traits as possible moderating factors between physician's speciality, career choice and well-being at work found that higher neuroticism was associated with higher psychological distress among obstetricians and gynaecologists, compared with general practitioners.33 This finding is in keeping with the observation that higher neuroticism has been associated with diminished well-being at work, emotional exhaustion, higher perceived stress and lower career satisfaction. An American study examining physician career satisfaction across different specialties found that obstetricians and gynaecologists express higher dissatisfaction compared with other specialties, and suggested that high expectations for birth outcomes, medicolegal risks, as well as personality factors could explain this association.34 As such, the utilisation of personality questionnaires could be adopted in medical school to enable students to have better insight into which speciality their personality would suit to succeed in. The breadth of skill-mix and variety of workload within O&G is vast, and therefore future studies should focus on the effect of personality on speciality and even sub-speciality career choice. PA has been extensively studied across many fields, such as music and sports, but surprisingly not in areas such as medicine, where patient care is at risk as a consequence. At present, there is a lack of insight into the true effects of performance anxiety among obstetricians and gynaecologists and its implications not only for patient safety, but also for recruitment, training, retention, job satisfaction and well-being. Future research into the prevalence of performance anxiety among obstetricians and gynaecologists would provide crucial insights into the factors that influence performance anxiety in O&G, such as personality, sub-speciality, gender and coping strategies. This would support further research to understand the impact of performance anxiety in O&G and pioneer targeted interventions and treatments. Proactive identification and early adaptation to the impact of arousal and anxiety on performance must be understood and managed at the beginning of the career trajectory to retain doctors in the medical profession, specifically in O&G. NHS practitioner health: The Trainee Doctors & Dentist Support Service (TDDSS) is a psychoeducation and support service that aims to offer a range of interventions to support trainees on programmes managed by HEE Local offices in London and the South East. It also offers computerised, telephone and face-to-face CBT for healthcare practitioners as well as psychotherapy and group psychotherapy. https://www.practitionerhealth.nhs.uk. Doctors in distress: Offers free-of-charge programmes and webinars for healthcare professionals throughout the year, aimed at promoting and protecting the mental health of healthcare professionals. https://doctors-in-distress.org.uk. Mindfulness for medics: Mindfulness for doctors is a national network that facilitates residential weekends for doctors and medical students who want to explore mindfulness-based practice personally and professionally. https://www.mindfulnessfordoctors.co.uk/. Royal Medical Benevolent Fund: Offers guidance from a careers coach regarding speciality choice. https://rmbf.org/get-help/help-for-doctors/doctor-advice-hub/two-ways-to-choose-the-specialty-thats-right-for-you/. British Medical Association: Offers a tool called ‘Specialty explorer’ for BMA members to match medical specialities with preferences and personality type psychometric testing. https://www.bma.org.uk/advice-and-support/career-progression/finding-the-right-role/specialty-explorer. Nothing to declare. MH and SN both wrote the manuscript. LK, SS and KJ provided guidance and helped revise the final draft. BPJ instigated and helped write the manuscript.