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

Researchers at Showa General Hospital, a regional tertiary care center, reviewed the records of nearly 2,700 patients admitted for acute abdominal disease between January 2016 and 2024. From that pool they identified 247 patients aged 85 and older who underwent emergency surgery, 220 of them within 48 hours of presentation and 27 after unplanned deterioration during conservative treatment. The cohort, published in Annals of Gastroenterological Surgery, was strikingly vulnerable: 44.9 percent had an American Society of Anesthesiologists physical status of 3 or worse, 35.6 percent were on anticoagulant therapy, and more than a third lived with dementia. The most common condition was strangulated bowel obstruction, followed by acute cholecystitis and mechanical bowel obstruction.

The headline result is a paradox that reframes surgical decision-making at the extremes of age. Overall postoperative complications occurred in 44.1 percent of patients, and major complications—graded 3 or higher on the Clavien–Dindo scale—affected 19.4 percent. Yet 72.1 percent of the cohort was discharged directly home. In other words, despite a complication rate that would alarm any surgical audience, the majority of these very old patients returned to their own lives rather than to nursing facilities or rehabilitation hospitals. The median postoperative stay was 11 days, with a range stretching from 1 to 76 days.

What determined who did badly was not birthday count but physiology. In multivariable analyses, a higher ASA physical status score and longer operative time were the dominant independent risk factors for both overall and major complications. Each additional point of ASA status roughly tripled the odds of a major complication, with an odds ratio of 3.52, and each additional hour in the operating room increased those odds by a factor of 2.10. Disease category mattered as well: conditions the researchers grouped as high-mortality—strangulated bowel obstruction, gastrointestinal perforation, and intestinal ischemia or bleeding—doubled the odds of any complication. By contrast, age per se did not predict complications at all.

Age did, however, shape what happened after recovery. The significant predictors of failure to return home were chronological age, dementia, and the occurrence of a major complication, with odds ratios of 1.17 per year of age, 2.34 for dementia, and 2.87 for a major complication. This divergence—complications driven by physiological reserve and operative invasiveness, discharge destination driven by age and cognition—suggests that the two central questions of emergency surgery in the very old, whether to operate and where the patient will go afterward, are governed by partly different factors and should be evaluated separately.

The study also dissects the money. All patients were treated under Japan’s Diagnosis Procedure Combination system, which bundles payment into a fixed per-diem component plus fee-for-service items such as rehabilitation, imaging, and additional procedures. Patients who suffered major complications stayed roughly twice as long, accumulated about 2.4 times the total inpatient claim points, and generated more than three times the fee-for-service costs of those who avoided major complications. Subgroup analyses revealed a grim linear gradient: cases requiring bowel resection with stoma creation fared worse and cost more than resection with anastomosis, which in turn fared worse than cases needing no resection. Contaminated infectious conditions produced longer operations, more blood loss, more major complications, and higher bills than ischemic events.

The most provocative finding lies in the patients who did not develop major complications. Using linear regression, the team modeled expected costs as a function of postoperative length of stay and calculated residuals—the gap between what each patient actually cost and what the model predicted. Among the 199 complication-free patients, a distinct subset clustered in the upper quartile of cost residuals, consuming disproportionate resources that were not explained by clinical severity or operative complexity. Critically, the excess showed up almost entirely in the fee-for-service component rather than in surgical procedure points or operating room consumables, pointing the finger at postoperative management: delayed resumption of oral intake, insufficient rehabilitation, and delayed discharge planning in patients who were otherwise clinically stable.

When the researchers ran the numbers on who landed in that excess-cost quartile, age and preoperative care dependency were conspicuously absent. Instead, higher ASA status, higher systemic inflammatory response syndrome scores, high-mortality disease categories, and longer operative times predicted inflated total costs, while greater blood loss predicted inflated fee-for-service costs. Splitting the cohort at the median stay of 10 days revealed another asymmetry: in short-stay patients, costs tracked ASA status, inflammatory burden, and operative time, whereas in long-stay patients only operative time mattered. Prolonged hospitalization without major complications, the authors argue, is a distinct clinical state—one driven less by initial severity than by the pace of postoperative recovery, where a failure to mobilize and eat early can cascade into prolonged stays and further functional decline.

The implications cut in two directions at once. On the clinical side, the study strengthens the case against using chronological age as a gatekeeper: surgical indication at this hospital was based on comorbidities, functional status, and anesthetic tolerance rather than age, and the results support that philosophy, particularly when paired with Enhanced Recovery After Surgery protocols emphasizing early mobilization, early feeding, swallowing rehabilitation, multimodal analgesia, and prompt catheter removal. On the economic side, the findings identify a realistic target for value-based reform. Costs tied to major complications should be accepted as the unavoidable price of treating fragile patients with life-threatening disease, but costs accumulated by stable patients lingering on the ward are potentially modifiable through intensified rehabilitation, nutritional support, and earlier discharge planning.

The authors are candid about the limits. The design was retrospective, so the super-elderly surgical cohort could not be compared with younger patients or with non-operated peers, and detailed geriatric frailty measures were unavailable. The claim data, while comprehensively audited, reflect reimbursement points rather than true hospital costs, and because the DPC system is unique to Japan, the cost findings may not transfer directly to other health systems. The cohort represents only those selected for surgery, not the full population of octogenarians with acute abdomens, so the true benefit of an aggressive approach remains to be tested prospectively. Even so, for a population that demographers expect to grow dramatically in Japan and beyond, the message is clear: well-selected patients over 85 can survive emergency abdominal surgery and go home, and the biggest opportunity to improve their care may lie not in the operating room but in the days that follow it.

Subject of Research: Short-term outcomes and cost drivers of emergency abdominal surgery in patients aged 85 and older

Article Title: Short‐Term Outcomes and Cost Drivers of Emergency Surgery for Acute Abdominal Disease in Super‐Elderly Patients: A Study in the Japanese Tertiary Care Hospital

Article References: Kobayashi, Y., Oikawa, R., Shibuya, Y., Tatsuno, M., Kamiyama, A., Ozawa, T., Hara, K., Hata, S., & Yamaguchi, H. (2026). Short‐Term Outcomes and Cost Drivers of Emergency Surgery for Acute Abdominal Disease in Super‐Elderly Patients: A Study in the Japanese Tertiary Care Hospital. Annals of Gastroenterological Surgery, 10(5), 1486-1495. https://doi.org/10.1002/ags3.70222

Image Credits: AI Generated

DOI: 10.1002/ags3.70222

Keywords: emergency surgery, super-elderly, acute abdominal disease, Clavien-Dindo classification, DPC reimbursement, ERAS protocol, length of stay, healthcare costs, geriatric surgery, tertiary care hospital, Japan, risk factors

The study was led by researchers from the Faculty of Medicine at the University of Peradeniya, including Jananie Abeygunasekera, Anushka Sachini, Malindi Kulathunga, Chathurika Abeysekara, Dulanjana Senavirathna, and microbiologist Veranja Liyanapathirana. Drawing on a descriptive cross-sectional design, the team surveyed 351 adult visitors attending the outpatient department of a tertiary care hospital. Participants were recruited consecutively using convenience sampling, meaning the researchers enrolled eligible adults as they presented, and data were collected through a structured self-administered questionnaire. The instrument probed perceptions of physicians’ attire and grooming, as well as beliefs about infection-related risks tied to what doctors wear. Statistical associations between perceptions and sociodemographic characteristics were tested using Pearson’s chi-square test or Fisher’s exact test, with significance set at a p-value below 0.05.

The headline result is unambiguous: scrubs dominate patient preferences. Some 200 participants, or 57.0 percent, identified scrubs as the preferred attire for male doctors, while 194, or 55.3 percent, said the same for female physicians. This preference was not uniform across the age spectrum. Among young adults, 65.5 percent favored scrubs for male doctors, compared with 54.2 percent of middle-aged adults and only 34.1 percent of older adults, a difference that was highly statistically significant. The same generational gradient appeared for female doctors, with 63.0 percent of young adults, 52.8 percent of middle-aged adults, and 34.1 percent of older adults preferring scrubs.

As enthusiasm for scrubs waned with age, preference for traditional attire climbed. The saree, a garment with deep cultural resonance in Sri Lanka, was favored for female physicians by 18.2 percent of young adults, 35.9 percent of middle-aged adults, and 54.5 percent of older adults, a pattern that reached strong statistical significance. The authors interpret this shift through a sociocultural lens: younger patients appear to associate modern, standardized clinical dress with professionalism and hygiene, while older patients may read traditional attire as a marker of respectability, identity, and trustworthiness. In other words, what counts as an appropriate doctor’s look is not a fixed visual code but one negotiated between global medical conventions and local cultural expectations.

Beyond aesthetics, the study tapped into a growing scientific concern: clothing as a fomite. Textiles in clinical environments can harbor bacteria and other microorganisms, and several studies worldwide have documented contamination of white coats, neckties, and sleeves. The Sri Lankan patients surveyed were notably aware of this risk. Fully 283 participants, or 80.6 percent, knew that microorganisms could survive on clothing, and 192, or 54.7 percent, perceived physicians’ attire as a potential source of infection. That more than half of ordinary outpatients independently view clothing as an infection vector underscores how far public awareness of cross-contamination has penetrated, even outside hospital wards.

When it came to ranking garments by infection risk, patients again converged on scrubs. Among those who viewed attire as a potential infection source, 136, or 70.8 percent, judged scrubs the lowest-risk option for male physicians, and 135, or 70.3 percent, said the same for female physicians. A remarkable 164 participants, or 85.4 percent of this subgroup, also considered short-sleeved attire more favorable for effective hand hygiene. This detail aligns neatly with infection control doctrine: bare forearms allow thorough hand and wrist washing, whereas long sleeves can dip into sinks, contact patients, and retain moisture and microbes. Patients, it seems, have internalized the same practical logic that guides hospital hygiene protocols.

The study fills a conspicuous gap in the literature. Much of the existing research on physician attire has been conducted in high-income settings such as the United Kingdom, the United States, and Japan, where debates have swung from the traditional white coat to bare-below-the-elbows policies. Evidence from South Asia and other low- and middle-income contexts has been sparse, despite the fact that cultural norms, climate, laundry infrastructure, and hospital resourcing differ substantially. By documenting patient perspectives at a major Sri Lankan hospital, the Peradeniya team provides data that hospital administrators and professional bodies in the region can use to ground attire policies in patient sentiment rather than imported assumptions.

The findings carry practical implications for hospitals weighing dress codes. Because scrubs are simultaneously the most preferred attire and the garment perceived as carrying the lowest infection risk, they occupy a rare sweet spot where patient preference and infection prevention goals coincide. Uniform scrub programs could, in principle, strengthen both patient confidence and hygiene practice, particularly if paired with short sleeves and institutional laundering, which reduces the burden on individual clinicians to maintain garment cleanliness. At the same time, the age-dependent preference for traditional attire suggests that any transition toward standardized dress should be communicated sensitively, since older patients may experience such changes as a loss of familiarity or respect. Grooming, too, emerged as part of the equation, with tidy appearance functioning in patients’ eyes as a proxy for both professionalism and safety.

The researchers caution that their findings come from a single tertiary care outpatient department and used convenience sampling, so the results may not generalize to all Sri Lankan patients or to inpatient settings. Still, the study, which received no external funding and was approved by the Ethics Review Committee of the Faculty of Medicine at the University of Peradeniya under protocol number 2024/EC/SP/02, adds an important data point to a global conversation about how doctors should dress. Its central message resonates well beyond Central Sri Lanka: a physician’s appearance is never merely cosmetic. To the patients who watch clinicians walk into the examination room, clothing communicates competence, cleanliness, and care, and it can either reassure or quietly alarm. As hospitals worldwide refine attire policies in the name of infection control, this study is a reminder that patients are not passive observers of those choices. They bring their own expectations, shaped by generation and culture, about what a safe and trustworthy doctor looks like, and those expectations deserve a seat at the policy table.

The symbolic weight of the white coat is worth recalling when interpreting these results. The garment entered medical fashion in the late nineteenth century, when physicians adopted laboratory dress to signal that medicine was becoming a scientific discipline grounded in germ theory and antiseptic practice. Over the following century the coat became so entrenched that many institutions staged formal ceremonies in which students received their first coat as a rite of passage. The Sri Lankan findings suggest that this historical emblem no longer commands automatic deference, at least among younger outpatients, who appear to associate standardized clinical uniforms rather than traditional professional dress with modern, hygienic care.

The study’s methodology merits some attention for readers weighing its conclusions. Because participants were surveyed with a self-administered questionnaire in an outpatient waiting area, the results capture stated perceptions rather than observed behavior. Perception and behavior can diverge: a patient may prefer scrubs yet still trust a physician in a saree once a consultation begins. The cross-sectional design also means the age gradient documented by the researchers could reflect either generational differences that will persist as younger cohorts age, or a life-stage effect in which attitudes toward traditional dress shift with maturity. Longitudinal work would be needed to separate these possibilities.

The finding that 80.6 percent of participants knew microorganisms can survive on clothing is striking given that textile contamination is a relatively technical concept. Research in other settings has recovered pathogenic bacteria, including staphylococci and enteric organisms, from the sleeves, pockets, and lapels of clinical garments, and contamination rates appear to rise with the frequency of patient contact and the interval between laundering. Whether contaminated attire translates into actual transmission of infection to patients remains difficult to prove, and direct evidence linking physician clothing to hospital-acquired infections is limited. This uncertainty has shaped policy debates, since some national guidance has restricted long sleeves and neckties on precautionary grounds even without definitive transmission data.

The Sri Lankan context adds further nuance. In tropical climates, lightweight and easily laundered garments offer practical advantages, and institutional laundering of hospital-owned scrubs can guarantee washing temperatures and detergent standards that home laundering of personal coats may not achieve. For hospitals in resource-constrained settings, however, supplying multiple sets of scrubs to every clinician carries real costs, which helps explain why traditional attire and personal white coats remain widespread across South Asia. Any move toward uniform programs must therefore balance patient preferences and infection control logic against procurement, laundry capacity, and staff acceptance.

Finally, the study highlights how patients themselves have become sophisticated participants in infection prevention culture. Public experience with hand hygiene campaigns and, more recently, pandemic-era messaging has familiarized ordinary people with concepts such as fomites and cross-contamination. That more than half of surveyed outpatients spontaneously identified clothing as a potential infection source indicates that hospitals can no longer assume attire is a neutral or invisible element of care. Patient-facing communication about dress codes, including why particular garments are chosen, may itself become a tool for building confidence in outpatient settings.

Subject of Research: Patient perceptions of physician attire and grooming and their perceived infection risks in outpatient care in Sri Lanka

Article Title: Patient perceptions of physician attire and perceived infection risk associated with attire and grooming in outpatient care at a tertiary care hospital in Central Sri Lanka

Article References: Abeygunasekera, J., Sachini, A., Kulathunga, M., Abeysekara, C., Senavirathna, D., & Liyanapathirana, V. (2026). Patient perceptions of physician attire and perceived infection risk associated with attire and grooming in outpatient care at a tertiary care hospital in Central Sri Lanka. Discover Social Science and Health. https://doi.org/10.1007/s44155-026-00481-9

Image Credits: AI Generated

DOI: 10.1007/s44155-026-00481-9

Keywords: physician attire, patient perceptions, infection control, cross infection, scrubs, ambulatory care, hand hygiene, cultural factors, Sri Lanka, developing countries, tertiary care hospital, grooming