Surgeon Temperament and Workflow Adherence During Custom Implant Procedures: An Exploratory Qualitative Study

Abstract

Patient-matched implants (PMIs) enable precise anatomical reconstruction but often introduce unforeseen intraoperative challenges that can provoke stress, reduce frustration tolerance, and influence surgical decision-making. Despite the growing clinical use of PMIs, the behavioural and psychological dimensions underpinning these challenging surgeries remain underexplored. This study examined the relationship between surgeon temperament, specifically frustration tolerance threshold, patience, and adherence to planned surgical workflows during PMI procedures. A qualitative thematic study was conducted over 22 months across two academic centres and 86 private surgical practices in South Africa. Data were collected through semi-structured interviews with consultant surgeons, assistant surgeons, surgical technologists, and biomedical engineers, supplemented by direct observation and detailed field notes. Inductive content analysis, thematic coding, and descriptive quantitative trends derived from Likert-style questionnaires were used to identify behavioural patterns associated with intraoperative stress and workflow deviation. Participant reports indicated that low frustration tolerance, often expressed as impatience, was perceived to be linked to increased deviations from surgical plans, including implant modification (reported in 4.6% of the 86 practices), even when design and fit were optimal. In 2.3% of the 86 practices surveyed, surgical team members reported incidents where impatience was perceived to have compromised patient safety. Stress inoculation theory and emotional intelligence frameworks offered explanatory models for the observed behaviours. Within the limits of this exploratory qualitative study, surgeon temperament—particularly mental preparedness and frustration tolerance—emerged as a recurring theme associated with intraoperative PMI workflow adherence. Whether these factors are determinants of workflow adherence whilst using high-fidelity PMIs, or merely correlated with other unmeasured variables, remains to be tested in future quantitative research.

1. Introduction

This thematic study suggests that surgeon temperament may influence intraoperative decision-making and potentially compromise surgical outcomes when using high-fidelity patient-matched implants. Here, we explore the intersection of surgical practice and behavioural psychology when utilising a novel technology.

Emotional discipline, specifically frustration tolerance as described by Albert Ellis’s Rational Emotive Behaviour Therapy (REBT) framework, is predicted to be a hidden determinant of workflow adherence in procedures where patient-matched implants are more accurate than the surgeon’s tolerance for handling technically finicky hardware [1]. The paradoxical challenge is that some patient-matched implants, while technically superior and highly precise, are often more difficult to implement surgically. This unforeseen difficulty can provoke low-level anxiety and stress in the surgeon, lowering frustration tolerance in the susceptible, and manifesting as impatience. This, in turn, may drive premature decisions, such as attempting to modify the implant before adequately assessing its suitability, thereby potentially compromising the surgical outcome.

Recent literature has increasingly recognised the role of surgeon behaviour and personality in surgical quality and innovation adoption. A protocol for a scoping review by Dhaliwal et al. [2] aims to identify modifiable surgeon behavioural factors influencing quality of care. Similarly, a systematic review by Bisset et al. [3] found that colorectal surgeons themselves acknowledge that their personality influences postoperative outcomes, decision-making, teamwork, communication, and operative risk-taking. Furthermore, Blohm et al. [4] demonstrated that Swedish female and male general surgeons differ significantly in personality traits—findings that may help explain variations in surgical outcomes based on surgeon gender. However, while the literature abounds with studies exploring surgeon personality and surgical outcomes or efficiency, few have examined the experience and temperament of surgeons using novel high-fidelity implants in the acute settings where short-term contextual factors, rather than stable long-term personality traits, determine intraoperative behaviour. While the Five-Factor model and other stable personality frameworks offer valuable insights into general behavioural tendencies, their predictive utility diminishes in short-term, high-stakes, or unfamiliar contexts [5]. Personality is not expressed uniformly across all situations; rather, behaviour emerges from an interaction between enduring dispositions and immediate situational demands [6,7,8].

2. Materials and Methods

This study is based on recurring clinical observations over a 22-month period drawn from two high-volume academic centres in Johannesburg, South Africa, and 86 specialist private surgical practices across the country. In addition to direct clinical observation, insights were gathered through semi-structured interviews with (1) six senior consultant surgeons (each with >10 years of experience incorporating three dimensional (3D) surgical planning in their practices in the surgical disciplines of craniomaxillofacial surgery, neurosurgery, and head and neck surgery, and plastic and reconstructive surgery), (2) four surgeons who routinely assume the role of first surgical assistant (3) four surgical technologists (with 8–15 years experience with intraoperative patient-matched implant handling) and, (4) two biomedical engineers from manufacturing companies, each with over a decade of clinical-facing design experience. The interview cohort collectively report direct involvement in over 400 surgical procedures involving prebent mandibular reconstruction plates (53 of which included patient-matched cutting guides for fibula free flaps), over 100 cranioplasties, and more than 40 custom temporomandibular joint (TMJ) arthroplasties. A smaller number of orbitozygomatic complex (OZC) reconstructions are also included.

Surgical disciplines involving craniofacial anatomy were intentionally selected, as these procedures demand exceptional precision, where millimetre deviation could be the difference between success or complication. In maxillofacial surgery, for instance, even minor variances in accuracy can drastically affect both function and aesthetics, where a millimetre deviation in orbital floor reconstruction can result in hypoglobus and associated diplopia, or submillimetre inaccuracies in mandibular reconstructions could result in malocclusion. Moreover, the author and interviewed colleagues have an average of 10 years’ experience within these surgical disciplines.

2.1. Participant Selection

The Participants were selected using purposive sampling. Inclusion criteria for consultant surgeons were: (a) minimum 10 years’ experience with patient-matched implants, (b) personal involvement in ≥20 PMI surgical procedures, and (c) current practice in craniomaxillofacial, neurosurgical, or head and neck surgical disciplines. For surgical technologists’ inclusion required ≥8 years of intraoperative experience with PMIs and for biomedical engineers, clinical-facing design experience with a minimum of 10 years’ experience designing PMIs.

In total, 16 individuals participated in formal or informal interviews: 6 consultant surgeons, 4 assistant surgeons, 4 surgical technologists, and 2 biomedical engineers. A total of 28 interviews were conducted (6 surgeons each contributed 2–3 impromptu interviews; the other 10 participants each contributed one formal recorded interview). The author directly observed 47 PMI procedures across the 86 practices. Of the reported events both extreme behaviours (attempts to break implants) were directly observed by the author; the unplanned modifications were reported retrospectively by surgical team members during interviews. The term “86 practices” refers to the number of distinct surgical practice locations (private practices or academic centres) from which at least one participant was drawn or where observations occurred.

2.2. Field Notes and Data Management

Field notes from observations and impromptu interviews were recorded within 2 h of each encounter, typed into plain text files, and organised chronologically by surgical procedure and participant role. All interview transcripts and field notes were imported into a shared secure folder accessible to the author and three research assistants. Data management and coding were conducted collaboratively using a combination of word processing software and spreadsheet tables, with no specialised qualitative analysis software. A consensus model was used: each research assistant independently coded a subset of the data. Initial coding disagreements were discussed in weekly team meetings until full agreement was reached. No formal inter-rater statistic was calculated, as the goal was consensus rather than reliability measurement. This approach is consistent with qualitative content analysis methods [9]. Sampling continued until thematic saturation was reached, defined a priori as three consecutive interviews yielding no new codes relevant to the research questions.

2.3. Data Collection

The data were collected over a 22-month period, from November 2023 to August 2025. Each surgeon had several informal and impromptu interviews (not all questions were necessarily asked in a single meeting) with notes taken by the interviewer. In contrast, assistant surgeons, surgical technologists, and biomedical engineers each participated in a single formal interview, which was audio-recorded and transcribed verbatim.

A semi-structured qualitative interview format using open-ended questions and a light quantitative Likert-style questionnaire was used to assess behavioural responses to intraoperative challenges, identify recurring themes related to surgeon temperament, and evaluate its perceived influence on the successful use of high-fidelity, patient-matched implants. An interview guide consisted of seven questions, including (1) “Can you give me your general impression of the intraoperative use of PMIs in terms of (a) a specific procedure, (b) difficulty/usability, and (c) outcome?”, (2) “Can you describe a situation where the workflow proceeded as planned?”, (3) “Can you describe a situation where the workflow did not proceed as planned?”, (4) “Can you tell me what strategies you typically use when PMIs do not perform as expected?”, (5) “Have you ever needed to modify a PMI due to difficulty?”, (6) “What led to a decision to modify an implant?”, and (7) “Do you have any further comments or thoughts regarding PMIs?” Questions five and six were reworded for assisting surgeons and surgical technologists as follows: (5) “Has a surgeon ever needed to modify a PMI due to difficulty? (6) In your opinion, what led him/her to that decision? If interviewees answered in the affirmative for question 3 then the following question was added, “What most likely contributed to the difficulty? 1—changes in patient’s anatomy, 2—errors in planning workflow, 3—inaccuracy of the biomodels (errors in 3D-printing), 4—other, or 5—unknown. Surgeons who participated in PMI surgeries as surgical assistants and surgical technologists were encouraged to speak freely and elaborate if they selected “other”.

Scored Likert-style questions included “List your surgical procedures that utilise PMIs in order of complexity (1—most complex, 5—least complex)”, “With which of the aforementioned surgeries are PMIs more difficult to use? (case n)”, “Which of these surgeries typically has the best fit PMIs? (case n, 1—best fit, 5—worst fit) and best outcomes (case n, 1—best outcome, 5—worst outcome). Optional free-text comment boxes followed each question, inviting participants to elaborate on their reasoning or describe specific surgical procedures that informed their responses. These qualitative comments were also analysed thematically and used to enrich the interpretation of numerical trends.

2.4. Data Analysis

All qualitative data were analysed using an inductive qualitative content analysis approach, focusing on manifest content to identify observable behavioural patterns and recurrent themes [9]. Interview transcripts were reviewed in their entirety and coded iteratively by the author and three research assistants. Open coding was used to assign descriptive labels to segments of text that reflected distinct attitudes, decision-making tendencies, and emotional responses related to intraoperative challenges with patient-matched implants.

Codes were then grouped into broader thematic categories through axial coding, with attention to the cognitive and behavioural dimensions underlying each response. Recurring patterns across interviews were clustered initially into three emergent themes, including: (1) attribution of fit-related issues, (2) intraoperative frustration and impatience, and (3) emotional regulation and perseverance (

Table 1. Initial emergent themes derived through inductive content analysis, showing axial coding categories and representative open codes with evidentiary sources.

Emergent Theme	Axial Code (Category)	Representative Open Codes	Data Source Evidence
Attribution of fit-related issues	Technical shortcomings	“Screw holes are misaligned (1–2 mm)”	Biomedical engineer report (BR1)
		“There is a contour mismatch at orbital rim”	Post-op debrief report (p. 6)
		“Inadequate flange thickness”	Post-op debrief report (p. 9)
	Planning workflow failures	“Soft tissue constraints ignored during virtual surgical planning”	Biomedical engineer report (BR2)
		“Poor DICOM segmentation”	Biomedical engineer report (BR3)
		“Surgical access was not anticipated”	Post-op debrief report (p. 7)
	Anatomical changes	“Unexpected bone resorption/remodelling since scan”	Post-op debrief report (p. 8)
		“Intraoperative tumour margin expansion”	Post-op debrief report (p. 8)
Intraoperative frustration & impatience	Verbal expressions	“This is BS, this thing doesn’t fit”	Assistant surgeon interview (Q3)
		“We’re wasting time now”	Assistant surgeon interview (Q4)
		“Why doesn’t this [expletive] thing work”	Surgical technologist interview (T1)
	Premature decisions	“Just bend the last three hole in”	Field note (24)
		“It is not placed where it is positioned the model, but it is sitting fine”	Field note (56)
		“Can you open the angle up?”	Surgical technologist interview (T3)
	Physical manifestation	“Aggressive burring of the implant where it interfaces the bone”	Field note (12)
		“Instrument slamming”	Surgical technologist interview (T3)
		“Manual recontouring of reconstruction plate”	Field note (58), Surgical technologist interview (T2)
	External or team-directed attribution	“I don’t know what the planner [biomedical engineer] did here”	Consultant surgeon interview (C1)
		“When I do these cases *, if a CBCT was used then it is always different from what we find, we must use a medical CT scan”	Consultant surgeon interview (C2)
Emotional regulation and perseverance	Protocol adherence	“Rechecked planning documents”; “Verified guide orientation”	Consultant surgeon interview (C3)
		“Re-sequenced steps”	Surgical technologist interview (T4)
		“Stripped additional soft tissue away and tried again”	Field note (32)
	Collaborative engagement	“Called for bioengineer (to theatre) consult”	Biomedical engineer interview (B1)
		“Asked consultant surgeon and surgical technologist for suggestions”	Surgical technologist interview (T3)

DICOM, digital imaging and communications in medicine; CBCT, cone beam tomography; CT, computed tomography. * The term “case” is used synonymously with “surgical procedure,” consistent with clinical terminology. Rather unexpectedly, two additional themes emerged, one as a subcategory of emotional regulation, namely, “mental preparedness” and perceived complexity as a stand-alone factor and inversely proportional to the frequency of divergence from the surgical plan (Table 2). These two additional themes were closely related and will be examined together.

). A coding tree illustrating how raw data led to codes, categories, and final themes is provided as Supplementary Table S1.

Reflexivity statement. The author is a surgical first assistant with 15 years of experience in craniofacial and PMI procedures, which provided insider access but may have influenced interpretation. To mitigate bias, data collection and coding involved three independent research assistants (non-surgical), and the author deliberately sought disconfirming evidence (e.g., system failures, implant design issues) from participants. Field notes were recorded within 2 h of each observation to minimise recall bias; informal interviews were not audio-recorded but were documented immediately. Thematic saturation was assessed by tracking new codes per interview; saturation was reached after 12 participants (no new codes in three consecutive interviews).

It should be noted that the frequency of modification in

Table 2. Surgical procedure, perceived complexity, and frequency of modification or divergence from the surgical plan.

Surgical Procedure	Perceived Complexity 1 (1—Least Complex, 5—Most Complex)	Frequency of Modification H, M, L 2
Orbitozygomatic complex reconstruction	1	H (12%)
Cranioplasty	1	M (3%)
Mandibular resection with reconstruction	2	H (10%)
TMJ arthroplasty	4	L (0%)
Mandibular resection with fibula free flap	5	L (2%)
TMJ arthroplasty with ankylosis	5	L (0%)

¹ Perceived complexity was rated on a 5-point scale based on qualitative data from participant interviews and thematic coding. ² Frequency of implant modification was categorised on three levels based on qualitative data from participant interviews and thematic coding. H, high; M, medium; L, low.

reflects both the physical possibility of modifying the implant (TMJ implants cannot be altered) and the surgeon’s decision to do so when modification is feasible; thus, the 0% rate in TMJ cases is partly a function of implant design. To ensure analytic rigour, each coded category was compared across professional roles (consultant surgeons, assisting surgeons, surgical technologists, and biomedical engineers) to identify convergence and divergence in perspective. Analytic memos were used to document interpretive reflections, and themes were refined through a series of 5 meetings between the author and three research assistants.

Quantitative data from the Likert-style questionnaires were analysed descriptively. Responses were tabulated to determine trends in perceived difficulty, implant fit, and outcomes across different surgical procedure types (e.g., cranioplasty, mandibular reconstruction, mandibular reconstruction with fibula free flap, OZC repair, and TMJ arthroplasty, either with or without ankylosis). These quantitative findings were used to triangulate qualitative insights, particularly in identifying whether behavioural factors corresponded with specific procedural challenges [10].

3. Results

Aberrant behavioural patterns, observed repeatedly by the interview cohort alongside reported instances of compromised intraoperative workflows, occurred with sufficient regularity to prompt a fundamental question: If the implant is accurate, yet the workflow is suboptimal, which part of the system has failed? Increasingly, the findings raise the possibility that surgeon temperament may play a role alongside design and planning factors. Our analysis consistently showed that low frustration tolerance among surgeons, overtly expressed as impatience, was associated with reports of increased intraoperative challenges and a lower perceived quality of procedural execution when using high-fidelity patient-matched implants, as reported by assisting surgeons and surgical technologists. Procedures perceived as “simple”–such as cranioplasty and OZC reconstruction, and to a lesser extent, mandibular reconstruction–were more frequently associated with diverting from the surgical plan and implant modification (Table 2). The TMJ surgical procedures involve implants that cannot be modified intraoperatively and therefore have reported modification incidence of 0%. The finding that no modifications occurred in TMJ surgical procedures suggests, but does not prove, that removing the option to modify may reduce the opportunity for impatience to influence intraoperative decisions. These findings are exploratory and hypothesis-generating; causal claims require quantitative validation.

Notably, in two instances (reported from two distinct practices, representing 2.3% of the 86 practices in the sample), surgeon impatience escalated to extreme behaviour, including physical attempts to break the implant as a demonstration of its perceived “poor quality”. It is important to note that this percentage reflects the proportion across all practices where such behaviour was reported by at least one team member, not the incidence rate per surgical practice. Without surgical procedure-level denominator data, no further quantitative inference is warranted. Both events occurred during straightforward cranioplasty procedures, contradicting expectations and suggesting that underestimating these ostensibly simple surgical procedures may have led to inadequate psychological preparation, increasing susceptibility to emotional dysregulation. This interpretation is supported by Ellis’s model of low frustration tolerance, which proposes that irrational beliefs about ease and control in stressful contexts increase emotional reactivity and maladaptive responses under strain [11]. These extreme responses represent 2.3% of the sample, while reported impatience resulting in intraoperative modification of a PMI occurred in 4.6% of surgical procedures (

Table 3. Observed behaviour, associated risk, and reported events (n = 86).

Observed Behaviour	Associated Clinical Risk	Reported Events 1
Physical attempt to break a PMI	Perceived compromise to patient safety 2	2 of 86 practices (2.3%)
Unplanned modification of a PMI (cutting, burring, recontouring)	Potential compromise to structural integrity, or to functional or aesthetic outcomes 3	4 of 86 practices (4.6%)

¹ These are practice-level counts, not procedural-level incidence rates. ² It is important to emphasise that the term “perceived compromise to patient safety” reflects the subjective reports of surgical team members, not objective clinical outcomes such as complications or implant failure. ³ The clinical significance of such modifications cannot be quantified within the scope of this qualitative study.

). It is important to acknowledge that not all intraoperative modifications attributed by interviewees to surgeon impatience were necessarily caused by temperament. Table 1 (initial emergent themes) shows that participants also identified technical shortcomings, planning workflow errors, anatomical changes, and imaging inaccuracies as contributors to implant-related difficulty. In many surgical procedures, these system-level factors may have preceded or exacerbated behavioural responses. The current analysis cannot determine the extent to which reported impatience was a primary cause versus a secondary reaction to genuine device or planning failures. Readers are cautioned against over-attributing workflow deviations to surgeon temperament alone.

In contrast to these emotionally reactive responses, other challenging surgeries elicited adaptive coping behaviours. For example, the most technically demanding procedures, bilateral TMJ arthroplasty with ankylosis, which were scored as the most complex surgical procedures, were associated with fewer intraoperative issues and greater adherence to the planned implant workflow, despite their longer durations and increased complexity. Interviewees emphasised that surgeons appeared to mentally “prime” themselves for the anticipated difficulty of these complex procedures, entering the operating theatre with greater psychological readiness and cognitive flexibility. One surgical technologist described it as follows, “Its as if they [surgeons] anticipated difficulties and psyched themselves up, like athletes do.” This finding is consistent with the theory of stress inoculation, in which anticipatory coping and mental rehearsal reduce the impact of procedural stress [12]. It also reflects principles of emotional intelligence, particularly self-awareness and self-regulation, which have been shown to influence surgical performance under pressure [13]. This was further evidenced by increased surgeon engagement in the virtual surgical planning process as reported by biomedical engineers, and more proactive communication with surgical team members prior to and during the procedure, as noted by assisting surgeons and surgical technologists.

4. Discussion

4.1. Background: The Psychology

The following psychological models are applied as interpretive lenses to help make sense of the observed patterns. Because no validated psychometric instruments were used, these frameworks are illustrative, not explanatory. Alternative system-level factors (implant design, planning errors, time pressure, staffing, training, communication barriers) are discussed in the “Background: The Surgery” section. Furthermore, this study did not measure irrational beliefs, frustration tolerance, or emotional intelligence. The application of these frameworks is retrospective and illustrative, not diagnostic.

From a psychological and behavioural perspective, particularly relevant to the surgical work environment and surgeon temperament, patience refers to the capacity to tolerate delay, difficulty, or frustration without becoming agitated, distressed, or reactive [14]. It is important to note that temperament is a multidimensional construct; the various terms used here (frustration tolerance, impatience, emotional dysregulation, mental preparedness, cognitive flexibility) reflect different facets of the same overarching psychological capacity. Furthermore, it is considered an individual’s ability to regulate emotional responses and maintain composure in the face of stress, uncertainty, or unmet expectations [15]. Patience is closely linked to emotional regulation, cognitive flexibility, and aspects of emotional intelligence, particularly impulse control and frustration tolerance.

In surgical contexts, patience may manifest as (1) sustained focus during complex or prolonged procedures, (2) willingness to troubleshoot unexpected challenges methodically, and (3) avoidance of impulsive or emotionally driven decisions under pressure.

4.2. Interpretive Frameworks (Theoretical Lens)

To conceptualise the intraoperative behavioural patterns observed in this study, and to consider theoretical bases for targeted psychological interventions, three psychological models were applied. The first of these is Albert Ellis’s Rational Emotive Behavioural Therapy (REBT) [16]. It is founded on the premise that emotional disturbances are largely a result of irrational beliefs rather than external events themselves. At the core of REBT is the ABC model, where A (Activating event) does not directly cause C (Consequence), but is mediated by B (Beliefs). A low frustration threshold (LFT), a key concept in REBT, arises from rigid, absolutist thinking, typically expressed as demands like “I must not be inconvenienced” or “Things must go my way”. These irrational beliefs foster intolerance to discomfort and adversity, leading individuals to perceive ordinary frustrations as unbearable, which in turn fuels emotional dysregulation and impulsive reactions.

The second theoretical framework is Meichenbaum’s Stress Inoculation Training, a preventative cognitive-behavioural approach aimed at strengthening an individual’s resilience to stress [17]. Stress inoculation training conceptualises stress management as a skill that can be developed through a staged process: identifying personal stress responses, acquiring adaptive coping strategies (such as cognitive restructuring and relaxation), and applying these strategies under simulated or actual stress conditions. In the context of intraoperative temperament, Stress Inoculation Training suggests that surgeons can be trained to better tolerate frustration and emotional pressure, rather than assuming such traits are inherent or fixed. This aligns with our observation that emotionally dysregulated responses often stem not from the objective complexity of the surgical procedure, but from a lack of anticipatory coping strategies when the surgery does not go as expected.

The third and final psychological framework combines the constructs of Emotional Intelligence (EI) and emotion regulation, drawing from the work of Arora et al. [13] and Gross [18]. Arora et al. [13] emphasise that EI, defined as the ability to perceive, understand, and manage one’s own and others’ emotions, is increasingly recognised as a critical skill within the Accreditation Council for Graduate Medical Education (ACGME) competencies, particularly in domains such as professionalism, communication, and systems-based practice. High EI has been linked to improved clinical decision-making, teamwork, and stress management under pressure. Complementing this, Gross’s process model of emotion regulation distinguishes between antecedent-focused strategies (e.g., cognitive reappraisal) and response-focused strategies (e.g., suppression), highlighting how individuals modulate emotional responses at different stages of experience [18]. Within the intraoperative setting, this framework explains how surgeons with higher EI and adaptive regulation strategies are better able to remain composed, reframe unexpected complications, and avoid escalation in environments with high clinical consequences. Conversely, those relying on maladaptive regulation (e.g., suppression or denial) may be more prone to frustration, impaired judgement, or interpersonal conflict. Together, these theories support the notion that temperament-related challenges in surgery are modifiable, psychological-based phenomena rather than immutable traits or a lack of technical skill. Moreover, patience serves as an “amplifier trait” that elevates surgeons who are able to utilise the technology effectively, to a level of surgical expertise. It is also worth noting that alternative theoretical perspectives exist, such as situational psychology and the need for closure [19]. These frameworks emphasise that contextual factors—for example, time pressure, administrative efficiency metrics, or operating room disruptions—can induce rapid decision-making and frustration regardless of a surgeon’s dispositional temperament. While our study focuses on individual psychological processes as the primary lens, we acknowledge that situational influences likely interact with temperament in complex ways. A comprehensive understanding of intraoperative behaviour would benefit from integrating both person-centred and situation-centred accounts. Furthermore, the behaviours observed in this study—frustration, impatience, and impaired communication—align with established frameworks of non-technical skills (NOTSS) in surgery, which include situational awareness, decision-making, teamwork, and leadership [20]. Similarly, the operating room teamwork literature emphasises that stress and emotional dysregulation can degrade team performance and increase error risk [21]. Our findings thus complement these existing models by highlighting the specific role of frustration tolerance in high-precision implant workflows. Future research should integrate temperament-based assessments with validated surgical human factors tools.

4.3. Hypothetical Implications (Speculative, Requiring Testing)

If the observed associations between frustration tolerance and intraoperative workflow deviations were to be confirmed in future quantitative research, several implications could be hypothesised. These are presented as speculative and should not be interpreted as practice recommendations at this stage.

Surgical training and preparedness. The finding that more complex surgical procedures were associated with fewer impatience-related deviations raises the possibility that psychological preparedness—akin to stress inoculation—might be enhanced through deliberate cognitive rehearsal before seemingly “routine” procedures. Surgeons might benefit from explicitly anticipating potential frustrations even in low-complexity surgical procedures, rather than reserving such mental preparation for obviously difficult surgeries.

Team dynamics and communication. The observation that adaptive surgeons engaged more proactively with surgical technologists and biomedical engineers suggests that communication patterns may mediate the relationship between temperament and outcomes. Future research could explore whether structured pre-operative briefings that explicitly address potential implant handling difficulties reduce frustration-driven deviations.

Implant design and choice architecture. The absence of modifications in TMJ surgical procedures (where implants cannot be altered) raises a hypothesis about choice architecture: when the option to modify is physically removed, surgeons may be forced to troubleshoot more patiently. This does not imply that non-modifiable implants are superior, but it suggests that design features that constrain impulsive actions might be worth investigating.

Selection versus training. An unresolved question is whether observed differences in frustration tolerance reflect stable personality traits (which might inform surgical selection or team composition) or modifiable skills (which could be taught). The current study cannot distinguish between these possibilities, but both warrant investigation using validated psychometric instruments linked to objective surgical outcomes.

What this study does not claim. It is critical to reiterate that this study did not measure patient outcomes, did not administer formal psychological tests, and cannot establish causality. The percentages reported (2.3%, 4.6%) reflect proportions of practices where behaviours were reported, not incidence rates per surgical procedure; thus, we do not claim statistical generalisability but rather identify a signal for future investigation. Any speculation about training, selection, or implant design must be tested in methodologically rigorous studies before clinical application.

4.4. Background: The Surgery

The emergence of patient-matched implants has transformed complex craniofacial surgery. These implants, designed from high-resolution imaging and fabricated through precise additive manufacturing (3D printing), offer a theoretical ideal: restoration of anatomical contour to within sub-millimetre tolerance, tailored to the unique defect and anatomy of the patient [22]. In principle, PMIs should eliminate estimation and reduce variability, thereby offering greater predictability of outcomes. In practice, however, this promise is not always fulfilled. It must be conceded that PMIs do not always meet clinical expectations. This may occur due to a range of factors, broadly grouped into three categories: (1) overt errors in the virtual digital planning phase (e.g., the biomedical engineer neglecting soft tissue constraints, inadequate consideration of surgical access, or poorly segmented DICOM data); (2) anatomical changes in the patient due to delayed or postponed surgeries; and (3) technical failures or inaccuracies in the 3D printing process. Interestingly, in such surgical procedures, there is often consensus among the surgical team and acknowledgement by the design engineers during post-operative debriefings that an error has occurred. These meetings typically involve a comprehensive review of the virtual surgical planning process, including re-verification of the printed moulds, cutting guides, and biomodels, in an effort to identify the nature and stage at which the error was introduced.

A further concession must be made to the reality that operating rooms are not always optimally prepared, nor are all staff adequately experienced or motivated, particularly in resource-constrained settings such as many South African hospitals. These conditions can create significant and legitimate frustration for surgeons, especially when compounded by the increasing pressure to meet administrative metrics of efficiency, throughput, and cost-effectiveness. However, while such stressors are acknowledged, they must not be allowed to compromise intraoperative temperament. Drawing on our earlier framing of patience as the capacity to tolerate delay and disruption without emotional dysregulation, we propose the concept of displaced impatience to describe the transference of frustration, originating from systemic inefficiencies, onto the surgical task or implant. When this occurs, the surgeon’s frustration threshold is lowered, increasing the risk of impulsive decisions or premature rejection of otherwise viable patient-matched solutions. This further underscores the importance of addressing low frustration tolerance in surgical professionals. We do not suggest that the operating suite can be free of stressors, but rather that surgical professionals develop the capacity to cognitively separate environmental stressors from procedural execution, thereby safeguarding surgical outcomes.

Among the traits explored, mental preparedness—as conceptualised in Stress Inoculation Training—may represent a psychologically salient determinant of intraoperative performance, particularly in scenarios where the surgical complexity of patient-matched implant solutions has been underestimated. This may be addressed by manufacturing agents marketing these devices responsibly, giving the surgeon realistic expectations. Furthermore, while experienced surgeons have referred to patient-matched implant use as “surgery by numbers”, a reductive comparison to “paint-by-numbers” art kits for children, this analogy does little to prepare less experienced surgeons for the often deceptively complex nature of these surgeries. This emphasises the role of responsible mentorship at training institutions in guiding the adoption of novel technologies in surgery. A particularly concerning observation emerged from two separate instances in which highly experienced surgeons, including a plastic and reconstructive surgeon and a neurosurgeon, attempted to break the patient-matched implant out of frustration when difficulties arose. In post-surgical debriefing meetings, these actions were not reflective of implant design failure but rather a breakdown in intraoperative temperament and systems thinking. Most alarmingly, the actions were taken without full awareness of alternative solutions available within the surgical workflow or operating room department. In such surgical procedures, patient safety was perceived as being directly compromised as reported by surgical technologists, highlighting the gravity of temperament-related behaviours. These behaviours, while isolated and representing only 2.3% of our sample (across 86 practices), nonetheless signal an emergent area of concern that warrants urgent further research and psychological intervention.

5. Limitations

This study has several limitations that should be acknowledged. First, the use of a qualitative methodology, while appropriate for exploring intraoperative temperament and psychosocial dynamics, is inherently limited in terms of generalizability. Unlike traditional surgical research, which often relies on quantitative metrics and standardised outcome measures, qualitative research emphasises contextual understanding and depth of insight. As such, the findings are exploratory and hypothesis-generating rather than conclusive.

Second, the study draws on subjective accounts from various members of the surgical team, including surgeons, surgical assistants, surgical technologists, and biomedical engineers. While this triangulation enhances credibility, the perspectives shared remain experiential and may not fully capture the internal emotional or cognitive states of the surgeon during high-stress intraoperative scenarios.

Third, while this study draws on established psychological frameworks such as Rational Emotive Behaviour Therapy, emotional regulation theory, and Stress Inoculation Training, these models were applied retrospectively and interpretively. Moreover, the concept of displaced frustration was derived from direct behavioural observation and thematic coding rather than formal psychological testing.

Fourth, patient outcomes were not included as part of the study design. This is not a minor limitation; it is central. Because the paper discusses patient safety and clinical compromise, the absence of direct linkage to objective outcomes such as complications, revisions, implant failure, or postoperative morbidity substantially limits the interpretability of the work. The findings reported here are perceptions of safety compromise, not measured safety events. Future studies must incorporate objective outcome measures before any causal claims can be made.

Fifth, the heterogeneity in interview methods—multiple informal interviews with consultant surgeons versus single formal interviews with other participants—was intended to enhance triangulation by capturing naturalistic, real-time reflections from surgeons while obtaining structured, comparable data from other team members. However, this difference may have introduced bias in the depth and richness of data across professional groups. While thematic saturation was achieved and findings were cross-validated across roles, this design feature limits direct comparability and is acknowledged as a methodological limitation.

Finally, thematic analysis, while methodologically sound, remains interpretive. Despite the use of independent coders and iterative review, the identification and framing of themes were necessarily shaped by the researchers’ perspectives and disciplinary backgrounds.

6. Future Directions

Before definitive interventions can be developed or implemented based on the observations presented here, further research is required to transition from this hypothesis-generating study to a formal, quantitatively grounded investigation. Broad adoption of any proposed strategies will depend on such progression. Subsequent studies should focus on the operationalisation of the key psychological constructs of frustration tolerance, cognitive flexibility, emotional regulation, and transferred impatience, and incorporate validated psychometric instruments to enable systematic psychological profiling and scoring. A notable limitation of the present study was the exclusion of direct patient outcomes. Future work should therefore explore potential associations between surgeon temperament, particularly in the context of utilising novel technologies, and clinical outcomes such as complication rates, implant revision, and long-term patient satisfaction.

7. Conclusions

Within the limits of this exploratory qualitative study, surgeon temperament—particularly mental preparedness and frustration tolerance—emerged as a recurring theme associated with intraoperative workflow adherence during PMI procedures. Although this study focused specifically on PMI procedures, the role of surgeon temperament and psychological preparedness likely extends to other surgical and medical domains where high-stakes decision-making under time pressure occurs. Whether these factors are determinants of workflow adherence, or merely correlated with other unmeasured variables (such as implant design, team dynamics, or surgical procedure selection), remains to be tested in future research that incorporates objective outcome measures, validated psychometric instruments, and larger, more representative samples.

Further research is required to inform the development of training programmes that screen for low frustration tolerance and prioritise cognitive and emotional preparedness as potentially essential psychological components. Surgeons should be supported, not only in technical training but in developing the cognitive resilience necessary to navigate unanticipated challenges without compromising the very technology designed to enhance patient outcomes. However, at present, no clinical recommendations regarding temperament-based screening or training are justified by this study alone.