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Making Average Performance Excellent: Mental Skills for Performance Enhancement

Nicholas E. Anton, MS, and Dimitrios Stefanidis, MD, PhD, FACS, FASMBS

September 1, 2018

Impact of Stress on Surgical Performance

While a reasonable amount of stress may help activate performers and sharpen their focus, extreme stress which exceeds one’s perceived ability to manage those demands can significantly deteriorate performance.1-2 The surgical education literature is replete with evidence that excessive stress can lead to several performance barriers for surgeons that can lead to intraoperative errors, which compromise patient safety.3-4 Intraoperative stressors for surgeons are frequent, and the sources include complex or rarely performed cases, poor assistance, issues with other staff members, and long turnaround times, among other factors.5 It appears that trainees experience significantly heightened stress compared to experienced surgeons, due to their inexperience managing intraoperative stressors.3,5

Impact of Chronic Stress on Health Care Providers’ Effectiveness

If left unmitigated, repeated exposure to high levels of occupational stress can manifest into burnout.6 Burnout is a psychological disorder characterized by depersonalization, a decreased sense of personal accomplishment, and emotional exhaustion.7 The impact of burnout can be pervasive, which includes occupational withdrawal, poor performance, and negative stress-related health outcomes. For surgeons, burnout is strongly related to major medical errors, which highlights a significant need to identify methods to help surgeons reduce stress and burnout.6

What Are Mental Skills?

The term “mental skills” refers to psychological strategies designed to help optimize performance by helping individuals consistently achieve their ideal mental state for performance.8 Some common performance-enhancing mental skills include goal setting and developing action plans, mental imagery, relaxation and attention management, and refocusing strategies. Mental skills are being implemented successfully with performers in high-stress domains such as elite athletes, police special forces, and U.S. Navy Seals.9-11

How Can Mental Skills Reduce Acute Stress and Optimize Performance?

A common physiological response to increased stress is fast, shallow, and irregular breathing,12-13 which can escalate and lead to hyperventilation and panic attacks.14 Heightened perceived stress has been associated with cognitive overload, decrements in attention (selective attention on task-relevant stimuli and sensitivity to verbal information),15-16 and slowed decision making.17 Mental skills interventions can help performers manage these stress responses effectively. Breathing-centered interventions that instruct learners to take slow, deep, and rhythmic diaphragmatic breaths help counter the visceral physiological response to stress.8,18-19 Attention and thought management strategies such as cognitive restructuring (identifying a negative thought and reframing it from a more positive perspective) and attentional refocusing (shifting concentration from stressful or task-irrelevant stimuli to more task-relevant stimuli) can also help significantly reduce perceived stress.19-20 Mental skills can further offer general performance-enhancing benefits.

Mental imagery, which is synonymous with mental practice, is the process of mentally creating quasi-sensory experiences in the absence of physical stimuli, which can produce realistic perceptual and sensory experiences.21-22 Mental imagery offers a number of benefits to performance including mental preparation, building confidence, focusing attention on task-relevant thoughts, identifying potential challenges and solutions, and priming muscles to perform by activating the same neural pathways that are activated during physical performance.22-24 Regarding surgical performance, these mental skills have been shown to enhance performance, particularly during stressful conditions.

Observed Impact of Mental Skills to Optimize Surgical Performance

Several studies have demonstrated the benefit of mental skills training to enhance surgical performance and reduce stress. In a randomized-controlled trial (RCT) where a stress management intervention was implemented with experienced surgeons, the groups of surgeons that received stress management training significantly outperformed controls on observed teamwork, use of coping skills, and stress levels.25 Researchers who implemented guided mental imagery training with novice and experienced surgeons found that imagery effectively enhanced participants’ confidence and knowledge to perform laparoscopic cholecystectomies.26 In a follow-up study, these researchers found that teaching surgical novices mental imagery led to significantly enhanced performance and shortened learning curves of laparoscopic cholecystectomies compared to controls.27

Recently, our research team has developed a comprehensive mental skills curriculum (MSC) and implemented it with surgical novices and residents with promising results. The MSC, which teaches learners skills such as imagery, goal setting, refocusing strategies, performance routines, and energy and attention management strategies, has been shown to reduce surgical novices’ stress,28 enhance laparoscopic performance from baseline to posttest,29 and lead to enhanced spare attentional capacity and laparoscopic skill retention over time compared to controls.30-31 The MSC was recently implemented in an RCT with surgery residents and the results indicated that MSC-trained residents significantly outperformed controls when laparoscopically suturing under stressful conditions.32 In addition to managing acutely stressful situations, mental skills can help manage chronic stress.

Mindfulness to Reduce and Prevent Burnout

Mindfulness has been defined as paying attention in the present moment in a sustained, non-judgmental way.33 Over time, mindfulness promotes enhanced awareness and attention regulation and manages emotional states effectively.34 Mindfulness-based interventions (MBI) have been shown to improve well-being and reduce stress in high-stress occupations, and mindfulness-based stress reduction (MBSR) has been shown to decrease healthcare providers’ emotional exhaustion, stress and anxiety, and improve their positive emotional state.34-35 A subsequent systematic review of the impact of MBSR on healthcare providers’ mental health found that MBSR interventions can reduce providers’ burnout, stress, and depression.36 However, in spite of this encouraging literature, few MBIs have been implemented with surgeons to our knowledge. 

Recommendations for Implementing Mental Skills Training in Surgical Education

Based on existing evidence in high-stress occupations outside of medicine and in surgery, comprehensive mental skills curricula should continue to be implemented with surgical trainees to enable them to manage acutely stressful situations. Moreover, the expansion of mental skills curricula to optimize the performance of the entire surgical care team may offer even greater benefits to patient care and safety. Lastly, due to the chronic high-stress nature of surgery, surgeons, particularly trainees, should be offered MBI to prevent and reduce burnout throughout the continuum of their careers.


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About the Authors

Nicholas E. Anton, MS, is the surgical skills coach for the department of surgery at the Indiana University School of Medicine, Indianapolis, IN.

Dimitrios Stefanidis, MD, PhD, FACS, FASMBS, is the vice chair of education, chief of MIS and bariatric surgery, and the director of surgical simulation for the department of surgery at the Indiana University School of Medicine, Indianapolis, IN.