Ready, steady…

It started four years ago. I squirm uncomfortably just thinking about it. I had been a doctor for nine years. I performed many procedures on children and babies with no problems – cannulas, lumbar punctures, skin biopsies, central lines, chest drains, umbilical lines, intubations, CPR, and defibrillation. This was just suturing.

My patient was just another child with a simple laceration on her forehead and parents who were extremely worried about the pain, the procedure, and the cosmetic outcome. I’d done a few already with no major problems. The child was having nitrous oxide but was still crying. Mum was on top, hugging her and holding her. I started the procedure. The mum started getting distressed too. And then it happened. My hand started to shake. The more I stared at it and willed it to stop, the worse it got. The nurse helping me noticed. The parents noticed. It was impossible to miss. If I had been holding a glass of water it would have been all over the floor. After the second stitch, the parents asked me to stop. I don’t blame them, if I’d seen a doctor coming towards me with a suture and hands shaking like that, I’d have done the same. Another doc finished the procedure for me. I shamefully retreated to another room to contemplate what had just happened.

That was the worst occasion, but it became a recurrent problem. After this, every time I went to suture, my hand shook. Even if I felt calm before it started, as soon as I picked up the forceps with the suture, I could feel the adrenaline rush, and my hand would go.

A paediatric emergency trainee who couldn’t suture. Not a good look.

What I experienced is related to performance anxiety. This is a term often used for athletes, musicians or actors, but really can apply to any situation where the presence of an audience increases your anxiety. In this case, an unfriendly audience vastly cranks up the pressure. In scientific terms, it’s the same as any other stress response – activation of the sympathetic branch of autonomic nervous system triggering a ‘fight or flight‘ response. Given that in a procedural situation, neither fleeing from the room, or attacking the family are reasonable options, then the symptoms of the adrenaline rush are channelled in another way. Wesner, Noyes, and Davis (1990) looked at university students at a music school and found that 47% of them experienced some performance impairment related to anxiety. This manifested as a rapid heart rate in 57% and trembling in 46%. Other symptoms included a dry mouth, sweating and shortness of breath.

The psychology literature describes Fear of Negative Evaluation (Watson and Friend, 1969), which may be a common problem for junior doctors and enhances performance anxiety. This is where people worry about how others perceive or judge them. They imagine that they are being perceived negatively, and their behaviour changes due to this.

This also relates to personality traits that exacerbate anxiety. Perfectionism is common amongst healthcare professionals and is where people have unrealistically high expectations of themselves. Perfectionists tend to focus on minor flaws and blow them out of proportion, rather than being able to step back and look at their overall performance and skills. Additionally, there is the trait of having the need to have excessive personal control. This means that when the circumstances are unpredictable or uncomfortable, the person feels like they will not succeed.

Therefore, rather than any actual consequence of failure, the person’s perception of this threat is inflated due to perfectionism, performance anxiety, fear of negative evaluation, and the need for excessive personal control. This is usually due to: overestimating the likelihood of the poor outcome happening; overestimating the severity of the poor outcome; underestimating what you can do about it yourself to cope, and underestimating what other people can do to help you manage.

Most of the literature on performance anxiety is around music and sport (Thomas and Nettelbeck, 2014). It is noted that performing alone is more anxiety-inducing than performing in a duet or trio or as part of a team. Performing privately is less stressful than performing publicly. However, it is not the case that the larger the audience, the more likely you are to develop performance anxiety. Proximity of the audience seems to be a factor – in particular being able to see the expressions on the audience members’ faces can play a huge role. In suturing, we usually have a small audience but they are very close by and we can hear and see their expressions and distress very clearly.

My situation was specific to the performance of a particular manual task. So, to tackle this, the approach needed to be a mixture of practical solutions to minimise shaking and to deal with the anxiety causing the shaking.

Know the procedure inside outside

Get some practice skin for suturing (this could be a banana skin or meat skin from the butcher). Practice for 15 minutes every day at home. Just do simple interrupted sutures (or whatever the procedure is) repeatedly. Ultimately, it becomes second nature, so your body knows how to do the procedure. This is known as procedural memory. It’s one less thing to worry about and helps you focus your concentration on relaxing.

Perfect and control your environment

Even though the symptoms are mainly due to anxiety, some practical solutions can help too. Make sure your chair is positioned at a good height. Position the equipment table close by and make sure it is easily accessible to you. Lay out your tools exactly as you want them. And the same goes for the parents. Be clear and confident before the procedure starts. If you prefer, tell the parents that they can stay in the room, but they have to sit in the corner (or wherever suits you so that they are not on top of you). Be clear that the child may well cry, but that the child will take comfort in them staying calm. The more stress they show, the more distressed their child will get. It is their role to be calm for their child during the procedure.

Limit the shaking

Anchor your arms on the bed or hold your elbows against the side of your body. Hold your arms like a T-Rex. Elbows in the air and hands together during suturing makes it easier for your hands to go wild when the shaking starts.

Talk to your colleagues

You will be surprised to find out what your colleagues have experienced. People also experience shaky hands for other procedures – blood taking, cannulation, and lumbar puncture. As one colleague put it: ‘everyone’s hand shakes to some degree. It is comforting to hear that you aren’t the only person who has experienced this, and it’s not insurmountable.

Talk to the family during the procedure

Make casual conversation during the procedure, with the child, or with the parents. This can help calm the patient/family but will also help relax you and take your mind off any anxiety about performing the procedure.

Relaxation techniques

Relaxation techniques can help minimise the physiological stress response (Reiss et al., 2016). Relaxation techniques can be used regularly or as part of your pre-procedure routine. This can take many forms – meditation, deep breathing, yoga, or your preferred mindfulness technique.

So, I did most of these things. I wanted to just avoid suturing ever again, I’ll be honest. But I love paediatric emergency, and a shaky hand for suturing isn’t really a good reason to abandon your career dreams. I worked hard for four weeks every day to perfect my technique and plan an approach to suturing. And it worked. Yes, my hand did shake a bit when I tried it again, but all the techniques meant that it did not impact on the family, the patient, or the suturing at all. And so my confidence grew. And now, four years later I can suture without any anxiety at all and rarely a tremor in sight.

We would love to hear your experiences – please get in touch by commenting on the post or emailing/tweeting tessardavis@me.com / @tessardavis

References

Mullen R. & Hardy, L. 2000,  State anxiety and motor performance: Testing the conscious processing hypothesis. Journal of Sports Sciences, 18; 111-120.

Reiss N, Warnecke I, Tolgou T, Krampen D, Luka-Krausgrill U, Rohrmann S. 2016, Effects of cognitive behavioral therapy with relaxation vs. imagery rescripting on test anxiety: a randomized controlled trial. J Affect Disord. 2016  pii: S0165-0327(16)31094-1. doi: 10.1016/j.jad.2016.10.039.

Thomas JP, Nettelbeck T, 2014, Performance anxiety in adolescent music students, Psychology of Music, 42(4); 624-634

Watson D, Friend R, 1969, Journal of Consulting and Clinical Psychology,33(4);448-457.

Wesner RB, Noyes R Jr, Davis TL. 1990, The occurrence of performance anxiety among musicians. J Affect Disord, 18(3):177-85.