Most Surgery Residents Carry Low-to-Average Anxiety Into the Operating Room, Survey Finds

Every time a surgical trainee scrubs in, a quiet physiological storm may be brewing beneath the sterile gown: a racing heart, a queasy stomach, a mind rehearsing every possible misstep before the first incision is made. This phenomenon, known as surgical performance anxiety, has long been whispered about in operating theater corridors but rarely measured with rigor. Now, a cross-sectional study conducted at a tertiary care teaching hospital in Peshawar, Pakistan, and published in Global Surgical Education, offers one of the most detailed portraits to date of how anxious general surgery residents actually feel when they operate, what triggers those feelings, and how the pattern shifts across the arc of training.

The research team, led by Muhammad Sabih of the Department of Surgery at Khyber Teaching Hospital, invited all 145 general surgery residents at the institution to participate in a census-style survey conducted between 1 and 31 May 2026. Rather than sampling a subset, the investigators approached the entire resident population, a design that strengthens the representativeness of the findings within this single center. A total of 122 residents responded, yielding an impressive response rate of 84.1 percent, high enough that the results likely capture the true distribution of anxiety across the cohort rather than the views of a self-selected few.

Measuring anxiety in a surgical context is a methodological challenge, because the construct borrows from performance psychology more than from traditional psychiatric screening. The researchers adapted a modified ten-item version of the Sports Competition Anxiety Test, or SCAT, an instrument originally developed to gauge competitive anxiety in athletes and previously adapted for a study of trauma and orthopedic trainees in the United Kingdom. The questionnaire asks respondents to rate how often they experience classic somatic and cognitive symptoms before and during operations: feeling uneasy before operating, worrying about not performing well, worrying about making mistakes, noticing a faster heartbeat, feeling a queasy stomach, or getting nervous while waiting to start a case. Each item is scored on a three-point frequency scale from rarely to often, and the responses are aggregated into a composite score.

The headline finding is, on its face, reassuring. The mean SCAT score across the cohort was 17.28 with a standard deviation of 3.05, and a 95 percent confidence interval running from 16.73 to 17.83. Interpreted against the instrument’s conventional bands, 45.9 percent of residents, 56 individuals, fell into the low-anxiety category, while 53.3 percent, 65 residents, showed average anxiety. Only a single resident, 0.8 percent of the sample, scored in the high-anxiety range. In other words, more than 99 percent of these trainees operate with anxiety levels that would not raise alarm on their own, a result that challenges the popular image of the perpetually terrified junior surgeon.

Yet the aggregate numbers conceal a more textured story that emerges when the data are sliced by training year. Scores peaked among PGY-3 residents, who recorded a mean of 18.29 with a standard deviation of 3.65, higher than their junior and senior colleagues. This mid-training spike is intriguing and fits a plausible developmental narrative: by the third postgraduate year, residents are handed progressively more complex cases and greater operative responsibility, while the hard-won confidence of the senior years has not yet consolidated. The researchers also found that citing acute intraoperative complications as a stress trigger varied significantly by training year, with a p-value of 0.047, suggesting that the emotional weight of a case going wrong is not distributed evenly across the training ladder.

To understand what actually stokes anxiety in the operating room, the team paired the SCAT with a checklist of technical, environmental, and non-technical stressors adapted from a United Kingdom-based study of practicing surgeons published in Annals of Surgery. The three most frequently cited triggers were strikingly concrete. Complex or high-risk cases topped the list at 66.4 percent, followed closely by equipment issues at 64.1 percent, and fear of negative evaluation by colleagues at 56.3 percent. The prominence of equipment problems is particularly notable, because it points to a stressor that is largely outside the resident’s control and potentially fixable through better-maintained instruments, reliable availability of devices, and clearer escalation pathways when technology fails mid-operation.

The fear of being judged by peers and attendings deserves equal attention. Performance psychology has long recognized that evaluation apprehension can degrade fine motor control and decision-making under pressure, a relationship formalized more than a century ago in the Yerkes-Dodson law, which describes how moderate arousal can enhance performance while excessive arousal impairs it. Surgical simulation research, including work by Kneebone and colleagues, has demonstrated that stress and coping styles measurably affect technical performance in simulated operations. When more than half of residents identify fear of negative evaluation as a trigger, the culture of the operating theater itself becomes a legitimate target for intervention, alongside individual coping skills.

One of the study’s most statistically robust findings concerns sex differences. Female residents were significantly more likely than their male counterparts to cite personal and family issues as a source of stress, with a p-value of 0.011. The authors did not measure the underlying mechanisms, but the result aligns with a broader literature on surgical workforce wellbeing, including systematic reviews documenting high burnout rates across surgical specialties and nationwide studies of resident stress in Switzerland and Saudi Arabia. In a health system where surgical trainees often work long hours with limited flexibility, caregiving burdens outside the hospital may compound the intrinsic pressures of training, and wellness programs that ignore this dimension risk missing the residents who need support most.

The study’s conclusions are carefully bounded. Most residents reported low-to-average surgical performance anxiety, but because specific stressors varied by training level and sex, the authors argue for tailored wellness interventions rather than one-size-fits-all programs. For PGY-3 residents, that might mean graduated exposure to complex cases with structured attending support; for those troubled by equipment failures, institutional investment and communication protocols; for residents worried about judgment, deliberate culture change and psychological safety initiatives; and for those carrying family burdens, scheduling and leave policies that acknowledge life outside the hospital. The authors also note the study’s limitations inherent in its design: it captures a single institution at a single point in time, relies on self-report, and cannot establish causal relationships between stressors and anxiety levels.

What makes this research resonate beyond Peshawar is its methodological honesty and its practical framing. By borrowing a validated instrument from sports psychology and a stressor taxonomy from UK surgical research, the team demonstrated that surgical performance anxiety can be quantified cheaply and quickly, using tools that other programs in low- and middle-income countries could readily adopt. The dataset, though not publicly available for confidentiality reasons, is accessible from the corresponding author on reasonable request, and the study received no external funding. The authors declare no competing interests, and the protocol was approved by the Institutional Research and Ethics Board of Khyber Medical College under Declaration of Helsinki principles, with written informed consent from all participants. As surgical education increasingly embraces wellbeing as a pillar of training rather than an afterthought, this study provides a template for measuring the invisible weight trainees carry into the operating room, and a reminder that the scalpel is only as steady as the mind guiding it.

Subject of Research: Surgical performance anxiety prevalence, severity, and triggers among general surgery residents

Article Title: Surgical performance anxiety (SPA) among general surgery residents in a tertiary care hospital

Article References: Surgical performance anxiety (SPA) among general surgery residents in a tertiary care hospital. (n.d.). https://doi.org/10.1007/s44186-026-00590-8

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00590-8

Keywords: surgical performance anxiety, general surgery residents, SCAT questionnaire, resident wellbeing, surgical education, tertiary care hospital, Pakistan, stress triggers, burnout, operating room stress, performance psychology, cross-sectional study