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Nexus of psychological and physical health impacts surgical performance, training
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I took up the study of sport psychology as a way of understanding and hopefully quantifying the “mind-body” connection. I went into the field for my patients, but soon I also became interested in how sport psychology principles could apply to surgeons.
Sport psychologists work to get athletes into their “zone” – the best physical and mental state for performance – and the same might be considered for surgeons. Hoping you are in the zone is not the same as getting in the zone with quantitative measures, such as warm-up exercises, imagery, proper rest, nutrition and other modalities. At the risk of heresy, I submit it is more important for your surgeon to be in the zone than your favorite team’s quarterback.
Getting in the zone implies having an expertise in that skill. With the limitation in resident work hours, there is a concern young surgeons will not get enough surgical time to achieve that expertise. Another concern that may conflict with surgeon performance is the trend in our society to achieve a “balanced” life. While there is ample evidence to illustrate that one should have a level of physical fitness to do something stressful like surgery, how do activities that take us away from our work impact our performance?
In this Orthopedics Today Round Table, we discuss these somewhat controversial topics, as well as explore the issues regarding the mind-body connection as it applies to surgical performance.
Daniel Fulham O’Neill, MD, EdD
Moderator
Roundtable Participants
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Moderator
- Daniel Fulham O’Neill, MD, EdD
- Plymouth, N.H.
- Brian P. McKeon, MD
- Boston
- Suzanne L. Miller, MD
- Boston
- Leonard Zaichkowsky, PhD
- Boston
Daniel Fulham O’Neill, MD, EdD: How do you prepare, especially mentally, for a day in the operating room (OR)? Do you do anything differently depending on your cases that day?
Brian P. McKeon, MD: Most of the mental prep I do is on the morning of surgery. Ever since my days as a student, I like to get to the test, or in this case the OR, a few hours early and have some peaceful moments to myself. I tend to visualize the day as a whole. Our job is repetition, habit and routine – the same thing almost every time, which includes my preparation. I like to exercise and listen to my favorite music. This serves as my imagery or meditation. When I call for the scalpel on the first case, I am energized, focused and ready to go.
Obviously, the physical component has other benefits. I think staying fit is incredibly important for a number of reasons. First, we have an incredibly demanding and physical job. You need stamina to make it through a long day in the OR or office. We must be on our game for every patient encounter. If we are tiring physically, then we will be tiring mentally and that is just not acceptable. Secondly, I think our patients need us to be fit and look good. The least we can do as physicians is to serve as a role model for health.
Suzanne L. Miller, MD: Like Brian, I start of every day with a treadmill run in the morning as I’m watching the news. Not to sound too multitasking, but this is when I’m also going through the day in my head.
O’Neill: Would you say that you wake up on an OR day with any kind of nervousness or excitement that might differ from a clinic day?
Miller: I feel like my life is always preparing, always organizing. Even on a clinic day, I’m going through the patients to make sure everything is in order. I do a lot of second opinions, so if there are any medical records sent to me beforehand, then I will review those. The key is to make the office visit synthesized and seamless instead of trying to do that when the patient is in the room.
O’Neill: Is running in the morning for your fitness or your sanity?
Miller: It is for fitness, for sports medicine, for everything. Staying fit absolutely makes me a more focused, more competent surgeon. I’m better for my family. I eat better. It just sets the tone for the day.
O’Neill: Much of what we’re hearing sounds like what we discuss with our athletes and can apply to any high-pressure, physical job. What is the science behind how you have your hockey players find their “inner Gretzky”? How could we relate it surgeons?
Leonard Zaichkowsky, PhD: K. Anders Ericcson, PhD, professor of psychology at Florida State University, who made famous the concept of “10 years and 10,000 hours” to achieve expertise, never focused on the mental prep but more on the physical prep. As many people have discovered, the two are intimately connected. In addition to athletes, many professions are appreciating the so-called mind-body connection. Medicine has been somewhat slow in making this part of the training.
Imagery is a learned skill and some people are better at it than others. In addition to the surgeon’s physical prep, we could use technology where perhaps on the morning or night before the operation, the surgeon could punch something up on iMovie to help get cognitively ready for surgery.
O’Neill: Do you discuss the types of physical and mental preparation you do with your students? Or do you consider this up to the individual?
McKeon: When working with students and fellows, we definitely not only model, but also emphasize the importance of the physical and mental side of surgery, and taking control of the OR. I talk to students about all the details of surgery – from where to put the scrub table, to table height, where to put monitor, and to how to put your body in the most efficient and ergonomic position. We must teach young surgeons everything – not just where to cut.
Miller: We all have tough cases and great surgery does not just happen. Every decision needs to be fussed over. I talk to the fellows about this and suggest articles to read and videos to watch. If it is something really complex, then we will do a dry run on a cadaver. Ultimately, there are no decisions in the OR that are neutral – everything is either a positive or negative. As the surgeon, you truly must think about and concern yourself with everything before showing up in the OR.
O’Neill: What research discusses the effectiveness of mental and physical preparation before a performance? Can we quantify such things and should this be part of surgical training?
Zaichkowsky: There is no question that the best decision makers on the ice, field or court, and the most optimistic athletes, are the ones who specifically train the cognitive and emotional systems. This is a big part of my job. We are starting to learn what is in the “black box” of the brain and how it responds to various stimuli.
One project I am part of is looking at functional MRI data while showing the subject game film using i-Movie. When athletes see themselves having success, there is increased blood flow to the prefrontal cortex and decreased blood flow to the hippocampus and anterior cingulate. Blood analysis also showed an increase in testosterone. We can do the same training with surgeons. All the systems can be turned on and fine-tuned by having surgeons ideally viewing themselves on short videos of performing successful surgery. A few medical schools are integrating this into their training programs by using simulation training.
O’Neill: Do you think the 80-hour work week and other measures people have discussed to find balance in their lives is good for our profession?
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McKeon: In my opinion, there is no question the capabilities of orthopedic residents have decreased. Most of this is lack of experience or as Len would say, they are getting fewer “reps” than in the past. Fellows come in undertrained with no understanding of the mental and physical aspects of surgery. What helped me when I was a fellow was moonlighting. The weekends of extra work allowed me to keep the surgical mentality and made me more independent and prepared.
Another part of problem is with the system. Reimbursements are decreasing so there is more pressure to load the schedule and now it is a time issue to the detriment of students. You have 10 surgeries to do and you want to do them well, and thus the attending is doing more of the operation.
Miller: I would agree. The climate of medical training and the quality of the fellows is changing and unfortunately not for the better. I don’t know exactly how to put this into words, but I think it is a product of the 80-hour training week. If you leave in the morning, then you don’t see what happens the next day. You are going to miss stuff. I can sense the gap between me and the fellows’ surgical skills is widening.
O’Neill: A lot of the push to diminish the work hours came from sport psychology and the concept of deliberate practice. In other words, the theory is the extra 20 hours or 40 hours a week most of us spent in hospital was not effective training because we were too tired to learn anything.
Zaichkowsky: Surgeons, like elite athletes, can engage in overtraining. The rigors of an NBA or NHL schedule require that we focus a great deal on the recovery of athletes. It is not possible to make fast and accurate decisions, control your emotions and have optimal motor control when you are tired. Therefore, I need to integrate the best knowledge we have about helping athletes recover. This includes getting adequate sleep, optimal nutrition, including supplements, proper hydration, and self-regulating stress responses.
Optimal performance by surgeons also requires that we engage in “best practices” to deal with fatigue. Whether the 80-hour work week accomplishes this is hard to say, but ultimately expertise in surgery can only be gained by doing a high volume of surgery.
O’Neill: Are we sending young surgeons the wrong message that they can have it all? Have they achieved the level of expertise and commitment necessary for this demanding profession?
McKeon: I think the high salaries young surgeons command coming out of residencies and fellowships might impede their progress. The concept of the 80-hour work week, certainly in the surgical specialties, might be backfiring. They are bright and smart but they’re not working hard enough, and as a result their technical capabilities are remarkably diminished.
Miller: I also think the shortened training time might work if you are doing an emergency room or radiology residency. But when a patient is admitted with a problem and you are operating on people and you don’t see them postoperatively, then this is detrimental to education.
O’Neill: What are your thoughts on the studies in the literature that support “balance” arguments?
Zaichkowsky: After studying “exceptional performance” across domains for about 3 decades, I am absolutely convinced that in order to be “world class” in any endeavor, you need to engage in deliberate practice for about 10 years. During this time, there is little time to get balance into your life as much as I want individuals to do so.
Once expertise is developed, I encourage all to cut back a bit and get some social and family balance in one’s life. It is possible to get some balance during those initial critical years, but it means partitioning the day and week into different segments, i.e., work skills, family life, social needs, etc. The trick is to make this partition distinct. For example, when time is set aside for family life, you then forget about the work demands for tomorrow.
McKeon: I do not know anyone who has reached a high level of expertise in our profession who has not had to sacrifice something in their lives – and unfortunately, it is usually family. This is a sacrifice. Your relationships must understand on some level what is going on. Obviously, your children are not given a choice in these decisions, and I know that I give up quantity with them and hopefully make up for it in quality. I truly try to make all of my time with my daughters as engaged and computer-free as possible.
As surgeons, we must achieve a level of expertise and develop our skill set before we can start talking about bringing down our handicap or getting to every soccer game. It might sound horrible, but I think because of the vocation we have chosen, we are often forced to place patients first and our family may come second at times.
Miller: There are not enough hours in the day to do it all. I can’t take my daughter to school, and I don’t pick her up from school. No question it is challenging, but I am also lucky to have a satisfying career and a wonderful supportive family.
O’Neill: For today’s children, what do studies show about their concept of achievement? Are we at risk of producing underachieving physicians and scientists?
Zaichkowsky: There is no good science behind this concept of giving children awards and thinking it will give them heightened self-esteem. Children can see through this – they know who the good players and students are. We are really giving the awards to parents. Not everyone can be “exceptional,” however, many of us can get pretty good, but we need to work hard at it.
In terms of risking future achievement, in our hyper-industrial computer age, we are not in danger of losing invention. There are just too many smart people who now have access to the Internet so I have no fear of lack of progress.
O’Neill: A lot of sport psychology is about improving performance. How do we get better as physicians and surgeons?
Zaichkowsky: I noticed this when I was working at the collegiate level, and all those kids wanted to be in the NHL. I tried to teach them to focus on hockey when it was time to play hockey and school when it was time to study – and not mess everything up when they had down time socially. The kids who had the skills and the discipline to not get distracted were the ones who went to the next level. This is again the concept of deliberate practice – concentrating on what you are doing at the moment, practicing as perfectly as possible and listening to your teachers and coaches. Certainly, in a surgeon’s hectic schedule, it is easy to lose sight of this.
Miller: Hopefully you recognize your mistakes so when things that don’t go smoothly you learn from that for next time. You learn what works for you in the OR in terms of anything from set up to anesthesia. You adjust your postoperative protocol according to how each patient does. You realize who to move along and who you need to hold back a little longer. I also have great partners, fellows and other colleagues to bounce off problems and ideas.
Zaichkowsky: One thing athletes do that surgeons do not is watch hours of non-edited video of themselves and others. Wayne Gretzky was preternatural at hockey and likely has a superior nervous system, but this does not mean other players cannot learn from him.
Although there are obvious weaknesses to apply this to surgeons, I would like to see simulation labs more available – and not just for surgeons in training. This is what we see in sports. What happens in the pros is quickly adapted by the colleges and amateur athletic clubs. It seems athletics have been more ahead of the curve than medicine although, of course, it might not be financially practical. Ultimately, this is part of what we are discussing in this Orthopedics Today Round Table – getting surgeons to prepare themselves like athletes. Using the surgical equivalent of deliberate practice, warming up, stretching out, cooling down. and learning how to recover would seem to me an incredibly positive change.
O’Neill: This discussion of surgeons as athletes reminds me of the age-old debate of whether we are physicians or technicians. I wonder if we should get back to the British system of addressing the surgeons as Mr. or Madame.
McKeon: While I certainly do not dismiss the importance of being a compassionate physician, like it or not, our priority as surgeons is to be good technicians. I think sometimes in training programs there is an overemphasis on the training room and seeing patients in the clinic. It is important, but if you do three clinics with a good shoulder surgeon, then I think you have it down. I think it is much more important to be technical.
Zaichkowsky: Certainly in the surgery business, but in almost any business, it is amazing how quickly we can be left behind if we don’t embrace change. Some of this is determined by the timing of a surgeon’s training, where they trained and how they trained. I think it is absolutely vital we seek out conferences and colleagues that help continue to develop our expertise because in fact, in most vocations, it is constantly changing and more and more technology based.
Miller: I agree. Like it or not, a huge part of our job is technical and we must be continually improving on that technique. Knowing that, we also know, while we might be able to get somewhat better results than someone else, we are still talking about a game of probabilities. I try to quantify the risks and benefits by describing there is an X percent chance of this, a Y percent chance of that. These are your chances. Some people do better and some people do worse.
McKeon: With great assistants, MRIs, etc., often most of the hard work is done. In some cases, people are willing to show up for surgery having never met their surgeon. They get worked up and then meet the surgeon in the OR. There is no question, we are, on some level, technicians.
O’Neill: In my talks to the American Orthopaedic Society for Sports Medicine, I have tried to act as the nexus between sports medicine and sport psychology. I think this panel has presented many of these ideas and hopefully this will serve as a point of departure for discussion and ultimately positive change. Thank you.
For more information:
- Brian P. McKeon, MD, can be reached at Boston Sports & Shoulder Clinic, 830 Boylston St., Suite 107, Chestnut Hill, MA 02467; 617-264-1100.
- Suzanne L. Miller, MD, can be reached at 830 Boylston St., Suite 107, Chestnut Hill, MA 02467; 617-264-1100.
- Daniel Fulham O’Neill, MD, EdD, can be reached at The Alpine Clinic, PLLC, 12 Yeaton Rd., Suite C4 Box #12, Plymouth, NH 03264; 603-536-2270; fax: 603-536-2277; email: doneill@thealpineclinic.com.
- Leonard Zaichkowsky, PhD, is professor at Boston University (retired) and now Director of Sports Science, Vancouver Canucks. He can be reached at email: sport@bu.edu.
- Disclosure: McKeon, Miller, O’Neill and Zaichkowsky have no relevant financial disclosures.