Surgeon Burnout: Understanding Cognitive Load, OR Stressors, and Practical Prevention Strategies

Burnout in surgical practice is more than long hours and heavy caseloads; it is deeply rooted in chronic cognitive strain and high-stakes decision-making. In this Q&A about her ACFAS ASC session, Dr. Maryellen Brucato explores how cognitive load in the operating room and perioperative workflow impacts performance, patient safety, and long-term career sustainability for podiatric surgeons. She also outlines practical, immediately implementable strategies to reduce mental overload without sacrificing outcomes.

Key Takeaways

1. Burnout in surgical practice is driven by both external stressors and invisible cognitive strain.
Beyond surgical complications and patient expectations, stressors such as discrimination, family pressures, and constant high-stakes decision-making activate a sustained stress response. In podiatric surgery, these pressures accumulate in uniquely intense ways.

2. Cognitive load in the OR directly affects performance and patient safety.
Intrinsic complexity, extraneous distractions (noise, unnecessary chatter, unfamiliar equipment), and germane demands (learning new procedures) all tax the surgeon’s mental bandwidth. Chronic overload leads to decision fatigue, brain fog, slower problem-solving, and increased risk of error, even among experienced surgeons.

3. Reducing cognitive overload requires intentional preplanning and protected mental space.
Simple strategies, such as rehearsing procedures, reviewing unfamiliar hardware in advance, minimizing OR distractions, scheduling deliberate breaks, and limiting digital interruptions, can significantly improve focus and sustainability. The most important mindset shift: recognize that much of the pressure surgeons feel is self-imposed, and self-compassion is essential for long-term performance.

Burnout is often discussed in general terms—but what does burnout look like specifically in surgical practice, particularly for podiatric surgeons working in high-pressure environments?

Drs. Emily and Amelia Nagoski in their book about burnout identify stressors that activate a stress response.¹ There are external stressors such as work (ie surgical complications), home life (ie partner feeling lonely when you're on call), expectations (ie patient expectations) and experiences of discrimination (ie patient asking you who will be performing the surgery). 

You focus on cognitive load as a major contributor to burnout—what are the biggest sources of cognitive overload in the operating room and perioperative workflow today? 

Cognitive load can be classified into three different categories.

• Intrinsic: Surgery has a high intrinsic cognitive load due to its complexity.
• Extraneous: This type of cognitive load is anything going into your brain that is being processed that can overload your brain such as extra noise in the OR (people in the room chatting loudly), the rep telling you about the product, or utilization of the product requiring extra steps for reasons you don't understand.
• Germane: For example, the demand for committing content to long term memory. Many of our procedures require preplanning and repetition especially the most complex ones. Or a procedure you're performing for the first time. The more you preplan and practice it will reduce the cognitive demand placed on your brain to remember all the things you must do to execute a well performed and thought-out surgery. 

How does chronic cognitive strain impact surgical performance, decision-making, and ultimately patient safety, even among highly experienced surgeons?

Cognitive strain leads to mental fatigue, brain fog, decision fatigue, etc. A surgeon's brain could be at its max and take too long to come to a conclusion about a surgical problem or maybe never arriving at a solution at all. 

Are there practical strategies surgeons can implement immediately—before, during, or after cases—to reduce cognitive load without compromising efficiency or outcomes?

Yes preplanning, practicing, and visualizing all the steps of the surgery can be helpful. Discuss the case with your resident or fellow, including what the plan is. Have a backup plan if your plan A doesn’t succeed. If you are using hardware you have never used before, take the time to read through the operative technique a day or two beforehand.

Additionally, during the procedure, implement strategies to minimize distractions, such as having the least amount of people in the room as possible and making sure all the equipment you need is in the room and ready to go. During clinic, taking deliberate breaks every 25 minutes can help. Go out and take a walk, or if you can't get out, do a mental lap. Think about something completely different or listen to music. You could meditate in your car. Allow your brain to process the patients and pathology you have treated. Minimize input to your brain. Put your phone in a different room or put it on “do not disturb.” 

If podiatric surgeons take away just one mindset shift or habit change from your lecture, what would you most want them to rethink about pressure, performance, and sustainability in their careers?

At the end of the day, the pressure we feel is the pressure we put on ourselves. We need to be compassionate to ourselves. Our brains are performing an incredible amount of processes in the background, and if we overload it, it will add to our stress. 

Dr. Brucato is the Owner of Brucato Foot and Ankle Surgery in Clifton, NJ.

Reference

1. Nagoski E, Nagoski A. Burnout: The Secret to Unlocking the Stress Cycle. 2019; Ballantine Books.