Mental Skills in Surgery: Lessons Learned From Virtuosos, Olympians, and Navy Seals.

OBJECTIVE: The present study investigated the role of mental skills in surgery through the unique lens of current surgeons who had previously served as Olympic athletes, elite musicians, or expert military personnel. BACKGROUND: Recent work has demonstrated great potential for mental skills training in surgery. However, as a field, we lag far behind other high-performance domains that explicitly train and practice mental skills to promote optimal performance. Surgery stands to benefit from this work. First, there is a need to identify which mental skills might be most useful in surgery and how they might be best employed. METHODS: Using a constructivist grounded theory approach, semi-structured interviews were conducted with 17 surgeons across the United States and Canada who had previously performed at an elite level in sport, music, or the military. RESULTS: Mental skills were used both to optimize performance in the moment and longitudinally. In the moment, skills were used proactively to enter an ideal performance state, and responsively to address unwanted thoughts or emotions to re-enter an acceptable performance zone. Longitudinally, participants used skills to build expertise and maintain wellness. CONCLUSIONS: Establishing a taxonomy for mental skills in surgery may help in the development of robust mental skills training programs to promote optimal surgeon wellness and performance.

Struggles with autonomy: Exploring the dual identities of surgeons and learners in the operating room.

BACKGROUND: Developing autonomy is a critical component of becoming an attending surgeon. General surgery training has evolved in recent decades, however, leaving residents less time to work with attendings to establish entrustment. Limited entrustment can impact resident learning and engagement. METHODS: A constructivist grounded theory approach was used to guide interviews of 12 general surgery residents and 10 attendings. RESULTS: Engagement in the OR is perceived by both residents and attendings as fundamental to achieving autonomy. Our study uncovered three key tensions: 1. Residents and attendings both occupy dual roles in the OR; 2. System demands put those roles in tension and opposition constantly; 3. Residents and attendings do deploy strategies to seek balance in those tensions. CONCLUSIONS: In an academic OR setting, competing priorities can negatively impact resident engagement. Participants described some strategies for helping residents and attendings prioritize learning and teaching to better prepare residents for future practice.

Complications: acknowledging, managing, and coping with human error.

Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication. Proper error disclosure includes a timely explanation of what happened, who was involved, why the error occurred, and how it will be prevented in the future. Medical mistakes afford the opportunity for individuals and institutions to be candid about their weaknesses while improving patient care processes. When a physician takes the Hippocratic Oath they take on a tremendous sense of responsibility for the care of their patients, and often bear the burden of their mistakes in isolation. Physicians may struggle with guilt, shame, and a crisis of confidence, which may thwart efforts to identify areas for improvement that can lead to meaningful change. Coping strategies for providers include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. Physicians and health care organizations need to find adaptive ways to deal with complications that will benefit patients, providers, and their institutions.

Prospective comparison of gadoxetic acid-enhanced liver MRI and contrast-enhanced CT with histopathological correlation for preoperative detection of colorectal liver metastases following chemotherapy and potential impact on surgical plan.

OBJECTIVE: To prospectively compare the diagnostic performance of gadoxetic acid-enhanced MRI (EOB-MRI) and contrast-enhanced CT (CECT) for preoperative detection of colorectal liver metastases (CRLM) following chemotherapy and to evaluate the potential change in the hepatic resection plan. METHODS: 51 patients with CRLM treated with preoperative chemotherapy underwent liver imaging by EOB-MRI and CECT prospectively. Two independent blinded readers characterized hepatic lesions on each imaging modality using a 5-point scoring system. 41 patients underwent hepatic resection and histopathological evaluation. RESULTS: 151 CRLM were confirmed by histology. EOB-MRI, compared to CECT, had significantly higher sensitivity in detection of CRLM ≤1.0 cm (86% vs. 45.5%; p < 0.001), significantly lower indeterminate lesions diagnosis (7% vs. 33%; p < 0.001) and significantly higher interobserver concordance rate in characterizing the lesions ≤1.0 cm (72% vs. 51%; p = 0.041). The higher yield of EOB-MRI could have changed the surgical plan in 45% of patients. CONCLUSION: Following preoperative chemotherapy, EOB-MRI is superior to CECT in detection of small CRLM (≤1 cm) with significantly higher sensitivity and diagnostic confidence and interobserver concordance in lesion characterization. This improved diagnostic performance can alter the surgical plan in almost half of patients scheduled for liver resection.

Diffusion-weighted and hepatobiliary phase gadoxetic acid-enhanced quantitative MR imaging for identification of complete pathologic response in colorectal liver metastases after preoperative chemotherapy.

PURPOSE: To evaluate the diagnostic performance of diffusion-weighted imaging (DWI) and gadoxetic acid-enhanced magnetic resonance imaging (MRI) to differentiate colorectal liver metastasis (CRLM) with complete pathologic response from those with incomplete response in patients treated with preoperative chemotherapy. METHODS: Gadoxetic acid-enhanced liver MRI and DWI were performed after completion of preoperative chemotherapy in patients with CRLM scheduled for liver resection. Metastases were classified as those with complete pathologic response (CR-CRLM) or incomplete response (IR-CRLM) according to postsurgical histopathology. Quantitative analysis was performed on non-contrast-enhanced images and hepatobiliary phase images following gadoxetic acid administration. Apparent diffusion coefficient values (ADC), normalized relative enhancement (NRE), and relative signal intensity difference (RSID) along with their diagnostic measures for detection of CR-CRLM were calculated for all lesions. RESULTS: In 23 patients, 10 CR-CRLM and 35 IR-CRLM (mean diameter, 21.2 mm) were evaluated. In CR-CRLM, ADC was significantly higher after exclusion of the outliers (p = 0.030); and RSID was significantly lower (p = 0.008). Combined indices range of ADC = 1.25-1.9 × 10(-3) mm(2)/s, NRE = 0-35% and RSID <120 had 60% sensitivity and 100% specificity for detection of CR-CRLM. CONCLUSION: DWI and gadoxetic acid-enhanced MRI appear promising for the detection of CRLM with complete response to preoperative chemotherapy. This could have significant implications for liver resection planning after preoperative chemotherapy.

Women in academic surgery: why is the playing field still not level?

BACKGROUND: The purpose of this study was to explore career satisfaction and advancement for women in academic surgery. METHODS: A 48-item web-based survey was emailed to women surgeons in academic centers across Canada, exploring career advancement, family planning, mentorship, discrimination, and career satisfaction. RESULTS: The survey response rate was 38% (81 of 212); 18% of participants felt they experienced gender discrimination in medical school, 36% in residency, 12% in fellowship, and 41% as staff surgeons. More than half felt that their gender had played a role in the career challenges they faced. Responses to open-ended questions suggested that many surgeons struggled to balance their academic careers with family life. Despite this, participants rated their career satisfaction very highly. CONCLUSIONS: There remain ongoing challenges for women in academic surgery including lack of gender equality, appropriate mentorship, and accommodations for surgeons with families. Continued advancement of women in academic surgery is dependent on addressing these concerns.

Pressures to "measure up" in surgery: managing your image and managing your patient.

OBJECTIVE: To identify pressures created by surgical culture and social setting and explore mechanisms for how they might impact operative decision-making. BACKGROUND: Surgeons apply judgments within a powerful social context and are constantly socialized and influenced by communicative exchanges. In this study, the authors characterized the nature of the surgical social context, focusing on the interactions between external social influences and the cognitive ability of the surgeon to respond to uncertain, unexpected, or critical moments in operations. METHODS: The authors reviewed the sociological and psychosocial literatures to examine concepts in identity construction, socialization process, and image management literatures and synthesized a conceptual framework allowing for the examination of how social factors and image management might impact surgical performance. RESULTS: The surgeon's professional identity is constructed and negotiated on the basis of the context of surgical culture. Trainees are socialized to display confidence and certainty as part of the "hidden curriculum" and several sociocultural mechanisms regulating "appropriate" surgical behavior exist in this system. In the image management literature, individuals put on a "front" or social performance that is socially acceptable. Several mechanisms for how image management might impact surgical judgment and decision-making were identified through an exploration of the cognitive psychology literature. CONCLUSIONS: Sociopsychological literatures can be linked with decision-making and cognitive capacity theory. When cognitive resources reach their limit during critical and uncertain moments of an operation, the consumption of resources by the pressures of reputation and ego might interfere with the thought processes needed to execute the task at hand. Recognizing the effects of external social pressures may help the surgeon better self-regulate, respond mindfully to these pressures, and prevent surgical error.

The role of liver resection for colorectal cancer metastases in an era of multimodality treatment: a systematic review.

BACKGROUND: To determine the role of liver resection in patients with liver and extrahepatic colorectal cancer metastases and the role of chemotherapy in patients in conjunction with liver resection. METHODS: MEDLINE and EMBASE databases were searched for articles published between 1995 and 2010, along with hand searching. RESULTS: A total of 4875 articles were identified, and 83 were retained for inclusion. Meta-analysis was not performed because of heterogeneity and poor quality of the evidence. Outcomes in patients who had liver and lung metastases, liver and portal node metastases, and liver and other extrahepatic disease were reported in 14, 10, and 14 studies, respectively. The role of perioperative chemotherapy was assessed in 30 studies, including 1 randomized controlled trial and 1 pooled analysis. Ten studies assessed the role of chemotherapy in patients with initially unresectable disease, and 5 studies assessed the need for operation after a radiologic complete response. CONCLUSION: The review suggests that: (1) select patients with pulmonary and hepatic CRC metastases may benefit from resection; (2) perioperative chemotherapy may improve outcome in patients undergoing a liver resection; (3) patients whose CRC liver metastases are initially unresectable may benefit from chemotherapy to identify a subgroup who may benefit later from resection; (4) after radiographic complete response (RCR), lesions should be resected if possible.

Interpreting three-dimensional structures from two-dimensional images: a web-based interactive 3D teaching model of surgical liver anatomy.

BACKGROUND: Given the increasing number of indications for liver surgery and the growing complexity of operations, many trainees in surgical, imaging and related subspecialties require a good working knowledge of the complex intrahepatic anatomy. Computed tomography (CT), the most commonly used liver imaging modality, enhances our understanding of liver anatomy, but comprises a two-dimensional (2D) representation of a complex 3D organ. It is challenging for trainees to acquire the necessary skills for converting these 2D images into 3D mental reconstructions because learning opportunities are limited and internal hepatic anatomy is complicated, asymmetrical and variable. We have created a website that uses interactive 3D models of the liver to assist trainees in understanding the complex spatial anatomy of the liver and to help them create a 3D mental interpretation of this anatomy when viewing CT scans. METHODS: Computed tomography scans were imported into DICOM imaging software (OsiriX) to obtain 3D surface renderings of the liver and its internal structures. Using these 3D renderings as a reference, 3D models of the liver surface and the intrahepatic structures, portal veins, hepatic veins, hepatic arteries and the biliary system were created using 3D modelling software (Cinema 4D). RESULTS: Using current best practices for creating multimedia tools, a unique, freely available, online learning resource has been developed, entitled Visual Interactive Resource for Teaching, Understanding And Learning Liver Anatomy (VIRTUAL Liver) (http://pie.med.utoronto.ca/VLiver). This website uses interactive 3D models to provide trainees with a constructive resource for learning common liver anatomy and liver segmentation, and facilitates the development of the skills required to mentally reconstruct a 3D version of this anatomy from 2D CT scans. DISCUSSION: Although the intended audience for VIRTUAL Liver consists of residents in various medical and surgical specialties, the website will also be useful for other health care professionals (i.e. radiologists, nurses, hepatologists, radiation oncologists, family doctors) and educators because it provides a comprehensive resource for teaching liver anatomy.

Slowing down when you should: a new model of expert judgment.

The study of expertise in medical education has tended to follow a tradition of trying to describe the analytic processes and/or nonanalytic resources that experts acquire with experience. However, the authors argue that a critical function of expertise is the judgment required to coordinate these resources, using efficient nonanalytic processes for many tasks, but transitioning to more effortful analytic processing when necessary. Attempts to appreciate the nature of this transition, when it happens, and how it happens, can be informed by the evaluation of other literatures that are addressing these and related problems. The authors review the literatures on educational expertise, attention and effort, situational awareness, and human factors to examine the conceptual frameworks of expertise arising from these domains and the research methodologies that inform their practice. The authors propose a new model of expert judgment that we describe as a process of slowing down when you should.

Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial.

OBJECTIVE: Surgical skills laboratories have become an important venue for early skill acquisition. The principles that govern training in this novel educational environment remain largely unknown; the commonest method of training, especially for continuing medical education (CME), is a single multihour event. This study addresses the impact of an alternative method, where learning is distributed over a number of training sessions. The acquisition and transfer of a new skill to a life-like model is assessed. METHODS: Thirty-eight junior surgical residents, randomly assigned to either massed (1 day) or distributed (weekly) practice regimens, were taught a new skill (microvascular anastomosis). Each group spent the same amount of time in practice. Performance was assessed pretraining, immediately post-training, and 1 month post-training. The ultimate test of anastomotic skill was assessed with a transfer test to a live, anesthetized rat. Previously validated computer-based and expert-based outcome measures were used. In addition, clinically relevant outcomes were assessed. RESULTS: Both groups showed immediate improvement in performance, but the distributed group performed significantly better on the retention test in most outcome measures (time, number of hand movements, and expert global ratings; all P values <0.05). The distributed group also outperformed the massed group on the live rat anastomosis in all expert-based measures (global ratings, checklist score, final product analysis, competency for OR; all P values <0.05). CONCLUSIONS: Our current model of training surgical skills using short courses (for both CME and structured residency curricula) may be suboptimal. Residents retain and transfer skills better if taught in a distributed manner. Despite the greater logistical challenge, we need to restructure training schedules to allow for distributed practice.