Anxiety: The Elephant in the Operating Room
Surgeons rarely talk about it, but we all feel it. Anxiety disorders have skyrocketed since the pandemic, and that hum of nervous energy seems to follow us everywhere. If you are a surgeon who also struggles with anxiety, please know, you are in excellent company.
To begin, it helps to separate fear from anxiety. We often use the words interchangeably, but they are not the same. Fear is immediate, intuitive, and useful. It protects us in real time. It’s what makes you run when someone breaks into your house or swerve when a car veers into your lane. Fear is a body-based survival signal that tells us to take action. Anxiety, on the other hand, is fear projected into the future. It’s the fear response applied to the imagination.
When we feel fear, our bodies take one of five classic actions: fight, flight, freeze, fawn, or flop. Most of us know the first three, but the last two can be just as life-saving in the right moments. Fawning—people-pleasing—is a defense mechanism we use to reduce perceived threat. Surgery culture has normalized the emergency response of fawning. In fact, culture rewards those of us who fawn hard. Think back to residency, when a chief resident or attending raised their voice and you responded with deference or over-accommodation. That was the fawn response at work. It’s an instinctual way to avoid harm, no different from an animal rolling on its back to signal submission.
Anxiety mimics the same physiology, but it’s triggered by imagined scenarios rather than real danger. It’s what happens when we apply our extraordinary creative capacity to worst-case scenarios. If we can imagine the best possible outcome and feel joy, we can also imagine the worst and feel dread in our bodies as though what we are imagining were real. The irony is that the very presence of anxiety proves that what we fear is not actually happening. You can’t be in mortal danger and anxious about it at the same time; if you were, fear would have already taken over and launched you into immediate action.
The other irony is that anxiety is rarely about what we think it’s about. On the surface, it may look like we’re worried about a surgical complication—a carotid injury, a CSF leak, a facial nerve transection—but underneath, we’re really anxious about what the event might mean: losing our livelihood, being judged, feeling humiliated, being sued, or disappointing a patient. Those meanings make anxiety sticky.
Sometimes it’s about how we imagine others will perceive us. Surgeons carry enormous pressure to appear competent at all times. I remember a complex sinus case early in my career where I back-bit the lamina and suddenly found myself looking at periorbita. My heart skipped, but I repaired it, and the patient did beautifully. Even as I tell the story now, a small part of me worries not only about being judged for making that stupid mistake, but also for fixing it (some rhinologists purport the lamina does not need to be repaired - I feel them judging me from their ivory towers). That’s how deep the conditioning runs. Our anxiety isn’t only about outcomes; it’s about reputation, belonging, and identity.
Physiologically, anxiety activates the same circuitry as fear: the amygdala, hippocampus, and cingulate gyrus flood the system with stress hormones like epinephrine and cortisol. If left alone, that chemical surge passes through in about ninety seconds. But when we attach a story to it—when our verbal left brain starts spinning narratives—it reinforces the loop. We see bleeding in the field and think, It’s carotid. Our heart rate spikes, sweat beads under our scrubs, and our brain insists the story must be true because we feel it so intensely. The more we buy into the narrative our imagination has created, the more our body reacts.
This is how anxiety hijacks our intuition. Instead of trusting our training, we catastrophize. Instead of curiosity, we default to panic. The mind’s ego resists evidence that contradicts its story, even hard facts in front of us. Neurologists describe this in stroke patients whose left brain denies ownership of their right hand (a condition known as asomatognosia). The human mind wants to find evidence that fits the narrative it believes to be true (hello, confirmation bias) and refuses to see clearly what doesn’t fit that story. That’s exactly what happens in the operating room when anxiety takes over.
We may look at the anatomy, verify with image guidance, and still disbelieve what’s in front of us. We might mistrust our equipment, double-check unnecessarily, and justify our excess actions as “an abundance of caution.” We might leave disease behind or underperform out of fear, then tell ourselves we were honoring “first, do no harm.” The reality is that we’ve let the anxiety loop block access to our wisdom.
When that happens, we have two options. The first option is to buy into the story. We know this option well. The second is to act as if we are not anxious. Breathe deeply and slowly instead of taking shallow breaths. Connect to your senses. Name what you see, hear, and feel in real time: “That’s middle turbinate. That’s lamina. That’s septum.” Ground yourself in certainty. Let the hormones wash through; it only takes about ninety seconds. If possible, shake it off afterward. Animals do this naturally, quite literally shaking off trauma after escaping a threat. We can do the same.
If the anxiety persists, the next step is to look at the thoughts underneath it. Identify what story your brain is telling you: You caused a CSF leak. You cut the facial nerve. You got into bowel. You hit the carotid. Bring the thoughts forward but don’t buy into them. As you continue working, ask yourself, “Do I absolutely know this is true?” The answer is almost always no.
Once doubt enters the story, curiosity can return. Curiosity moves us out of the anxious left brain and into the calm, connected right brain. From there, we can access our training, knowledge, and intuition—the very tools that make us excellent surgeons. Staying in the anxious loop blocks recall, reasoning, and creativity because the brain thinks survival is at stake. Calm curiosity reopens access to skill.
Suppressing anxiety doesn’t work either. What we resist persists. Unacknowledged anxiety eventually surfaces as frustration, anger, or irritability. It often leads to overcontrol—an attempt to manage uncertainty with ritual or superstition. We start believing that a certain pair of socks, scrubs, or earrings will keep the world in order. It’s a false sense of control born from fear.
The opposite of control is creative response. The Indian spiritual teacher Amit Desai Guruvé describes it as “existing in perpetual creative response to whatever is present.” That’s exactly what great surgeons do when they’re at their best. A bleeder appears; we tamponade, we pause, we think. We adjust, improvise, and continue, not from panic, but from presence. It’s like surfing waves instead of fighting the ocean.
Imagine showing up to surgery, to your family, to your entire life that way: steady, adaptable, creative. Not reckless, but responsive. Not driven by control, but guided by skill and awareness. That’s mastery.
There is nothing wrong with being a surgeon who feels anxiety. In fact, I’d argue that you’re embodying courage every time you step into the operating room. Anxiety can be a superpower when understood and managed. It sharpens awareness, builds empathy, and connects you to the human experience of your patients, every one of whom, by the way, is anxious about their own operation.
I’ve come to see my anxiety as a teacher. It has made me brave, compassionate, and attuned. It reminds me that courage is not the absence of fear; it’s moving forward while it’s present. Anxiety doesn’t make you weak. It makes you human. And when you learn to work with it instead of against it, it can make you extraordinary.
