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ABSTRACT: Training and practice in medicine are inherently stressful. The effects of stress on performance in clinical situations are poorly understood. The purpose of this study was to examine the stress responses and clinical performance of residents during low and high stress (HS) simulated trauma resuscitations.
Thirteen emergency medicine and general surgery residents were evaluated in HS and low stress (LS) trauma resuscitation simulations. Subjective and physiologic (heart rate, salivary cortisol) responses were measured at baseline and in response to the scenarios. Performance was assessed with global rating and checklist scores of technical performance, time to record critical information, and the Anesthesia Non-Technical Skills tool. Post-scenario recall was assessed with the completion of a standardized trauma history form.
Post-scenario subjective stress and cortisol levels were higher in the HS scenario compared with the LS scenario (p < 0.05). Checklist performance scores and post-scenario recall were significantly lower in the HS compared with the LS condition (p < 0.05).
In trainees, some aspects of performance and immediate recall appear to be impaired in complex clinical scenarios in which they exhibit elevated subjective and physiologic stress responses. The findings of this study highlight a potential threat to patient safety and demand further investigation. Future studies should strive to further elucidate the effects of stress on specific components of performance and investigate ways to reduce its negative impact.
The journal of trauma and acute care surgery. 02/2012; 72(2):497-503.
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ABSTRACT: Surgical training in the operating room includes acquiring technical skills and cognitive knowledge. Technical skills training on simulated models has been shown to improve technical performance in the operating room, and may also enhance the acquisition of other skills by freeing cognitive capacity. This has yet to be investigated.
We conducted a single-blinded randomized controlled trial to assess the effect of ex vivo technical skills training on cognitive learning in the operating room. Eighteen novice surgical residents were randomized to 2 groups. All participants were taught the basics of fascial closure and performed 1 closure on a low fidelity synthetic model. Residents in the intervention group practiced on the models until technical proficiency was reached. Residents in the control group had no further contact with the models. All residents then performed a fascial closure on a patient in the operating room while listening to a script that contained relevant clinical information. A validated evaluation tool was used to assess the technical merit of the closure. Finally, all participants completed a multiple-choice test designed to test the information retained from the script.
The technical performance of the ex vivo trained group was significantly higher than that of the untrained group (P = 0.04). The ex vivo trained group also performed significantly better on the cognitive retention test (P = 0.03).
Technical skills training using a low fidelity synthetic simulator resulted in improved technical performance in the operating room, and enhanced the ability of residents to attend to cognitive components of surgical expertise.
Annals of surgery 03/2011; 253(5):886-9. · 7.90 Impact Factor
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ABSTRACT: In the initial phases of surgical training, attentional resources are monopolized by the execution of novel tasks. This consideration can result in overwhelming attentional resources, leaving few for other tasks. Practicing a technical task decreases the attentional resources required for its execution. These resources are then free for redistribution to other, clinically important tasks. This pilot study investigated how laboratory-based surgical training on a technical procedure affects concurrent acquisition of other, nontechnical information.
After watching an instructional video, 16 first-year surgical residents performed a pyloroplasty procedure and were divided randomly so half received 6 trials of hands-on practice of the procedure (practice group) whereas the other did not (no practice). After 1 week, participants returned to perform the procedure on 2 tests: isolated procedural performance (transfer) and concurrent procedural and listening performance (dual). Procedural and listening performances were compared between groups using expert measures of performance (Global Rating Scale [GRS], task-specific checklist, and number of errors) and written test scores.
GRS and error scores reflected greater practice group performance on both tests: transfer test (P < .05 for all measures) and dual test (GRS, P < .05; error, P < .001). Most important, the practice group also retained more clinical information, indicated by higher written test scores (P < .001).
Findings in this study suggest that practice outside of the operating room may result in a decrease in attentional resources dedicated to technical task execution, thus facilitating trainees' ability to distribute attentional resources between concurrent, clinically important task performances.
Surgery 01/2011; 149(1):1-6. · 3.10 Impact Factor
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ABSTRACT: OBJECTIVES Training and practice in medicine are inherently stressful. Research into the effects of acute stressors has revealed significant variability in individual responses to stressors, with performance impairments occurring in those who demonstrate elevated subjective and physiological responses. Cognitive appraisals (subjective assessment of situational demands and available resources) of a stressor have been proposed as a predictor variable in stress responses. However, the relationship between cognitive appraisal and stress responses has not been tested empirically in complex realistic situations. The purpose of this study was to determine the extent to which cognitive appraisal affects a medical trainee's subjective and physiological stress responses to high-acuity simulated clinical situations. METHODS Thirteen emergency medicine and general surgery residents participated in high (HS) and low (LS) stress trauma resuscitation simulations. Subjective (cognitive appraisal and State-Trait Anxiety Inventory [STAI]) and physiological (salivary cortisol) measures were collected at baseline and in response to participation in each scenario. RESULTS Post-scenario STAI scores, cognitive appraisal and cortisol levels were higher in the HS scenario compared with the LS scenario. For the participants who appraised the scenarios as 'threats' (in which the demands outweighed the resources), the ratio of perceived demands to resources was positively correlated with cortisol levels (r = 0.59, p < 0.05) and STAI responses (r = 0.64, p < 0.05). By contrast, for the participants who appraised the scenarios as 'challenges' (in which resources were sufficient to meet the demands), the perceived ratio of demands to resources was not correlated with either the STAI scores or cortisol levels. CONCLUSIONS Subjective appraisals of a situation appear to play an important role in stress responses, which have previously been shown to impair performance. As such, training for high-acuity events should include interventions targeting stress management skills.
Medical Education 06/2010; 44(6):587-94. · 3.18 Impact Factor
