Surgeons in training may benefit from mental visualisation
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.e8611 (Published 07 January 2013) Cite this as: BMJ 2013;346:e8611
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Sonal Arora is right that mental visualisation could help improve surgical performance. Positive imagery is one of several mental skills that are common between successful surgeons and athletes, others include distraction control, self-belief and constructive evaluation [1].
Unfortunately, simply teaching mental skills to surgeons in training will do little to help them deliver outstanding performance. We need to redesign our working lives as surgeons in order to allow the mental preparation needed for elite performance before we operate. It is unthinkable that Tom Daley would take a call about a dive he was doing later in the week moments before climbing the ladder to compete. Yet this is what surgeons are expected to do, dealing with multiple competing demands whilst preparing to operate, particularly on emergency cases.
In order to perform like athletes, surgeons need to prepare like athletes. This means total focus on the case in hand and protecting time spent in the operating suite from all other demands.
1, Macdonald J, Orlick T, Letts M. Mental readiness in surgeons and its links to performance excellence in surgery. Journal of Pediatric Orthopedics 1995;15(5):691-697
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This may also be of interest:
http://blogs.bmj.com/bmj/2012/09/13/domhnall-macauley-mental-rehearsal-i...
Competing interests: No competing interests
This concept of mental visualisation is not a new technique. Atheletes have been using it, and the analogy of surgical training with atheletes is good but not entirely correct. The introduction of Cbds, minicex, OSATS and other tools to assess training has formally structured it to an extent but there is no evidence that it makes better doctors in surgical skills than they may be on paper. Self motivation, mental imaging and persistence with an aim to achieve and continuously excelling at what we waent to achieve ar very important along with self belief. It was really enlightening to read this article in an era where everything has become so much evidence based without an emphasis on enhancing the basic values of human nature.
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I enjoyed the article regarding the use of mental virtualisation for surgeons, comparing them to professional athletes. I would argue that this technique is not just applicable to surgeons, but to all specialties that engage in practical procedures.
As a trainee anaesthetist I am often called to wards, or emergency departments, for trauma or cardiac arrest calls, situations that require high pressure practical and mental skills. I, and many of the colleagues I have discussed this with, use a visualisation technique, mainly by recalling the appropriate Advanced life support or equivalent algorithm as I walk to the department.
Whilst I appreciate that discussion of the technique is to be lauded, I would argue that it is a long-standing technique, certainly within anaesthetics.
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Re: Surgeons in training may benefit from mental visualisation
As a surgical trainee, I read this article with great interest and am acutely aware of the importance of perfecting my practical surgical skills. It is well recognised that surgery is an apprenticeship, more so than training in other specialities. Changes in work patterns to shifts and modern legislation such as the European Working Time Directive (EWTD) have meant that the apprenticeship-style is not as applicable to surgical training as it once was and, we need new innovative ways of maximising the available time at work1.
The analogy between elite athletes and surgical trainees is an interesting one and true. Surgical training does not stop when one has finished their shift, but continues into one’s personal time and requires a certain degree of self- sacrifice, motivation and determination to continue with studying for postgraduate exams, general and specific reading and, working on projects to achieve posters and publications. The multi-faceted nature of surgical training requires the ability to concentrate on a given task especially when given the infrequent opportunity to carry out a practical procedure that one may not have performed for some time. This requires a degree of readiness in order to maximise the opportunity and perform to such a level that would increase the chance of future opportunities. McDonald et al assessed the mental factors associated with surgical excellence using a ‘Surgeons Interview Guide’ based on Orlick’s “Model of Human Excellence”. Of the three readiness factors, mental, technical and physical, the surgeons questioned rated mental readiness as the most important. Mental readiness encompassed commitment, self-belief, positive imagery, mental readiness, full focus, distraction control and constructive evaluation.
The technical aspects of surgery require a certain degree of automatization, as if working on ‘auto-pilot’ especially when carrying out the same procedures. Anecdotes from consultant surgeons suggest that carrying out a procedure in the same way each time minimises the risk of complications, allowing one to trace their steps should a complication occur. Anyone with experience of attending an operating theatre will appreciate the level of activity that continues in the background and distraction control is paramount.
Technical automatization with concurrent distraction control was significantly different in junior and experienced surgeons such that junior surgeons were easily distracted and unable to process cognitively based math problems by paying more attention to the surgical task, whereas the experienced surgeons were unaffected3. Self-belief does not necessarily predict technical success 4, where junior surgeons whose high scores on general self-efficacy questionnaire correlated negatively with laparoscopic performance compared to more senior surgeons, in whom self-belief was independent of technical skills.
Interestingly, you highlight mental visualisation as a technique of reducing performance related stress. Discussion of a procedure prior to its execution, with a senior surgeon can help improve situation awareness and intra-operative decision-making skills surely goes hand-in-hand with technical automatizaion. After all, the wining in surgical practice is to carry out procedure safely, with no intra-or post-operative complications and the patient discharged back to continue with their normal life.
This highlights the complexities of surgical training and it is a topic that will continue to evolve. More importantly, it needs trainers to evolve so they can best guide their trainees to becoming the successful, competent, well-rounded and safe surgeons of the future.
References
1. Monkhouse S, Learning in the Surgical Workplace: Necessity Not Luxury, The Clinical Teacher, 2010; 7(3):167-170
2. McDonald J, Orlick T, Letts M. Mental readiness in surgeons and its links to performance excellence in surgery. Journal of Pediatric Orthopedics. 1995; 15(5): 691-7
3. Hsu KE, Man FY, Gizicki RA, Feldman LS, Fried GM. Experienced surgeons can do more than one thing at a time: effect of distraction on performance of a simple laparoscopic and cognitive task by experienced and novice surgeons. Surgical Endoscopy. 2008; 22(1): 196-201
4. Maschuw K, Osei-Agyemang T, Weyers P, Danila R, Bin Dayne K, Rothmund M, Hassan I. The impact of self-belief on laparoscopic performance of novices and experienced surgeons. World Journal of Surgery. 2008; 32(9): 1911-6.
Competing interests: No competing interests