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Self-monitoring in Surgical Practice: Slowing Down When You Should
Abstract
Self-regulation is the cornerstone of autonomy for any profession, with surgery a classic example. Each surgeon must regulate
his or her own performance paying attention to what matters and thinking clearly during the moment-to-moment activities of
daily practice. To be effective self-monitors of our choices, behaviour, decisions and judgement, we must understand the cognitive
processes at work within us. This chapter explores various literatures that inform the way surgeons think and how they monitor
their thinking so that they ‘slow down when they should’ during the critical aspects of practice. The concept of mindful practice
is introduced as a method for gaining control over the self-monitoring activities of daily performance.
... 22 Moulton et al. identified slowing down as a crucial component of medical expertise, coining the phrase "slowing down when you should." 23 They characterized pausing as the most extreme form of slowing down. 24 While slowing down has been described as a cognitive process that may accompany physical manifestation, we further specify pausing as a cognitive and temporal process grounded in the physical world. ...
... Research has shown that vigilance produces a tangible amount of cognitive load, 34,37 which means performers should always reserve sufficient capacity for this process in working memory. 23 To stress the importance of this reservation, we suggest a new typology of cognitive load: primary load (PL) caused by domainspecific primary tasks (e.g., a surgical task), secondary load (SL) from domain-general processes that support the primary tasks (e.g., self-monitoring during surgery), and extraneous load (EL) that does not contribute to the tasks (e.g., distracting conversations during surgery). Thus, the targets of selfmonitoring are narrowed down to two constructs: whether the room for SL is reserved and whether the total load is below the limit. ...
... The main contribution of this work lies in that it connects key concepts in safety culture that have been discussed in different contexts and brings them back to the fundamental principles of the medical pause. We have linked the practical observations and strategies from studies on slowing down phenomena identified by Moulton et al. 20,23,33 and checklists by Pronovost et al. [68][69][70] We then recognized the cognitive mechanisms shared between the basic concepts in these studies and integrated them within a broad range of clinical activity. This will move the literature one step further as it supports the arguments of the previous studies on formal or informal timeouts and allows future researchers to build upon the literature through our newly developed understanding. ...
Research has shown that taking “timeouts” in medical practice improves performance and patient safety. However, the benefits of taking timeouts, or pausing, is not sufficiently acknowledged in workplaces and training programs. To promote this acknowledgment, we suggest a systematic conceptualization of the medical pause, focusing on its importance, processes, and implementation in training programs. By employing insights from educational and cognitive psychology, we first identified pausing as an important skill to interrupt negative momentum and bolster learning. Subsequently, we categorized constituent cognitive processes for pausing skills into two phases: the decision-making phase (determining when and how to take pauses) and the executive phase (applying relaxation or reflection during pauses). We present a model that describes how relaxation and reflection during pauses can optimize cognitive load in performance. Several strategies to implement pause training in medical curricula are proposed: intertwining pause training with training of primary skills, providing second-order scaffolding through shared control, and employing auxiliary tools such as computer-based simulations with a pause function.
... 10,11 In this study, we were specifically interested in how stress was experienced by surgeons and whether stress indices could identify surgeons' 'slowing down' moments. 12 However, stress was difficult to identify in any one individual for several reasons: there were no absolute levels of HRV or cortisol that indicate stress, 13,14 perceived stress was not synonymous with physiologic stress, 13 and physiology measurements and emotional scales lacked the contextual depth that is important to understanding stress in actual practice. We, like others, 15,16 have started to look beyond the reductionist approach for understanding stress in surgery. ...
Background
Physician stress impacts patient care and provider wellness. Researchers have largely used reductionist approaches to study stress (e.g. focusing on physiology). This study sought to understand surgeons’ subjective experiences of stress in the workplace, using a holistic perspective.
Methods
Using a constructivist grounded theory methodology, semi-structured interviews were conducted with 24 staff surgeons at the University of Toronto, purposively sampled for specialties and experience levels.
Results
The stress experience was reconceptualized as a variable and multidimensional state of fracture, comprised of physiologic, cognitive, emotional, sociocultural, and environmental facets.
Conclusions
Reconceptualizing surgeon stress as a multidimensional state of fracture may help surgeons recognize the contributing facets and identify appropriate strategies for promoting wellness and optimizing performance.
... 36 Work in this area has outlined how becoming aware of automatic reactions can allow individuals to learn to respond more deliberately and modulate the outcomes. 32,33,37,38 Mindful practice is viewed as a way to become more aware of how one is reacting, 33,38 and mental skills may be employed to help an individual respond more appropriately. 29 Cognitive and physiologic responses are not the only factors influencing performance: emotions play a critical yet underappreciated role. ...
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.
... The quality of "subsidiary awareness" (Polanyi, 1969) kept those gut feelings close to the threshold of awareness, yet not interfering with the automatic processing that was necessary to get through a busy day of clinical practice. His "attentiveness in automaticity" (Moulton & Epstein, 2011) is one feature of mindfulness that fostered the early recognition of novel elements in this particular situation as opposed to others that might superficially seem similar. This discernment occurred during an otherwise familiar and somewhat ritualized encounter and triggered uncertainty, mental flexibility, and slowing down in order to characterize it further. ...
Distraction in health care is best seen as a mismatch between capabilities (of individuals, teams, and organizations) and the nature of the work that they must accomplish. Mindful practice refers to ways of enhancing those capabilities. Focusing attention on what is most important in the workplace can be achieved by enhancing self-awareness within individuals, situation and emotional awareness within teams, and the structure of healthcare organizations. Collectively, these efforts can affect quality of care, human relationships, and sustainability of the healthcare workforce. Individual, team, and organizational change strategies all require development of attentive observation, critical curiosity, beginner’s mind, and presence. I propose ways of optimizing the healthcare work environment through contemplative practices, team training, and organizational redesign to address distractions that emanate from within one’s one mind as well as those coming from the workplace.
... 21 All of these interpretations consider that how routine or intuitive the expert has become is less relevant than how the expert reinvests his or her cognitive processes continuously and is able to apply a 'beginner's mind' to a situation when necessary. 22 Adaptive experts were purposively sought for interview. Interviewees were identified through either the personal experience of orthopaedic surgeons (EFI and MDR) or on the recommendation of another orthopaedic surgeon with an interest in medical education. ...
ContextGood preparation for surgical procedures has been linked to better performance and enhanced learning in the operating theatre. Mental imagery is increasingly used to enhance performance in competitive sport and there has been recent interest in applying this in surgery. Objectives
This study aims to identify the mental imagery components of preoperative preparation in orthopaedic trauma surgery and to locate these practices in existing socio-material theory in order to produce a model useful for surgical skills training. Methods
Semi-structured interviews were conducted with nine orthopaedic surgeons. Participants were identified by personal recommendation as regularly performing complex trauma operations to a high standard, and by affiliation to an international instruction course in trauma surgery. Interviews were audio-recorded and transcripts were independently analysed using thematic analysis. ResultsAnalysis revealed that surgeons interact intensively with multiple colleagues and materials during their preparatory activities. Such interactions stimulate mental imagery in order to build strategy and rehearse procedures, which, in turn, stimulate preparatory interactions. Participants identified the discussion of a preoperative plan' as a key engagement tool for training junior surgeons and as a form of currency by which a trainee may increase his or her participation in a procedure. Conclusions
Preoperative preparation can be thought of as a socio-material ontology requiring a surgeon to negotiate imaginal, verbal and physical interactions with people, materials and his or her own mental imagery. Actor-network theory is useful for making sense of these interactions and for allowing surgeons to interrogate their own preparative processes. We recommend supervisors to use a form of preoperative plan as a teaching tool and to encourage trainees to develop their own preparatory skills. The ability of a trainee to demonstrate sound preparation is an indicator of readiness to perform a procedure.
Medicine and surgery can be demanding professions with high levels of burnout, but few healthcare professionals are given training or education in the management of stress, and the ability of individuals to cope with work and other pressures is often taken for granted. Emotional resilience - the ability to recover from a stressful event, whether at work or at home - is influenced by factors that are both within and outside our control. In this review, we provide an overview of emotional resilience for surgeons and other healthcare professionals, and focus on the factors that can be modulated to help us cope with difficult or complex situations. We also discuss the importance of teamwork and camaraderie, which can easily be forgotten in busy working practice. A greater awareness and understanding of emotional resilience and ways to cope with stress and pressure at work are essential if we are to look after ourselves better, improve the work of our teams, and provide the best care for our patients.
Purpose:
American Pediatric Surgical Association (APSA) committees send monthly email blasts to members with links to peer-reviewed publications. This study assesses the utilization of this service.
Methods:
Email-opening and click-through rates were analyzed from 5/2012 to 4/2017 and compared to APSA and industry standards. Access was analyzed based on subject, disease type, journal, impact factor, and committee. CME questions were added in 10/2014 and emails consolidated in 1/2016. Effects of these changes were analyzed.
Results:
Over 60 months, 281 articles were distributed from 58 journals. Access increased significantly with impact factor (P = 0.0039). Overall email opening rate (53% ± 3%) and click-through rate (37% ± 10%) were significantly higher than all APSA emails (43%,18%, P < 0.0001) and 2017 industry standard (26%,12%,P < 0.0001). Access rates differed significantly between the twenty-five topics covered (P < 0.0001), with the highest access for appendicitis (240 ± 79, P < 0.0001). Common condition articles (157 ± 93) were accessed more than rare (55 ± 60, P < 0.0001). With email consolidation, opening rates increased (53 ± 3 to 55 ± 2, P = 0.003) and click-through rates decreased (40 ± 9 to 30 ± 8, P = 0.0002). By adding CME questions, opening rates increased nonsignificantly (52 ± 3 to 54 ± 2, P = 0.066) and click-through rate decreased significantly(41 ± 10 to 33 ± 9, P = 0.001).
Conclusions:
APSA email blasts are valued by members based on high access rates. Click-through rates have declined, potentially indicating user fatigue. APSA members prefer common conditions and high impact factor journals. These data will help refine this service.
Level-of-evidence:
Level III.
Mindful practice refers to health professionals' capacity for moment-to-moment self-awareness, self-monitoring, and self-regulation in the service of safe, effective, and compassionate health care. These qualities are especially important with the increasing pace, complexity, and demands of providing health care to a growing and aging population. Mindful practice starts with cultivating the observing self, critical curiosity, beginner's mind, and presence. In clinical practice, these capacities are associated with mindful attitudes, such as adopting multiple perspectives on a clinical situation, attention to context, considering facts as conditional, seeing novelty in familiar situations, modulating reactivity and considering diagnostic categories as provisional. In turn, these attitudes are linked to adopting a nonjudgmental stance, greater clarity in decision-making, greater autonomy-supportive behavior and compassion, all key features of patient-centered care. Mindfulness is also linked to greater resilience and well-being in the healthcare workforce, and has potential to reverse the trends toward burnout, attrition and alienation. The latter sections of the chapter provide illustrations and evidence regarding the effects of mindful practice on quality of care, quality of caring, clinician resilience, and well-being. The final section focuses on how mindful practice might be promoted through institutional and individual efforts involving trainees and practicing clinicians.
In this paper the concepts from activity theory (AT) are applied for identifying the challenges and contradictions emerging in surgical resident's curriculum based training at hospital. AT is utilised as a lens to identify contradictions that cause disturbances, problems, ruptures, breakdowns, and clashes which emerge while surgical skills training is implemented in a new way at hospital. We especially aim at finding solutions for contradictions which emerge while the new and old working culture are confronted and the workers are required to balance themselves between the patient care demands and workplace learning requirements. We are using the conceptual theoretical approach to describe the phenomenon of surgical working.
In 1976, Selye first associated stress with disease.¹ He defined stress as a generalized nonspecific set of responses to protect the organism from harm. Stress has been further studied and its definition refined by many authors. The term “fight or flight” has been used to define the body’s response to stressful stimuli, with increased heart rate, increased blood pressure, and increased oxygen consumption via stimulation of the sympathetic nervous system, for one example. The stress response, however, as it affects the individual, is actually a far more complex and far-reaching physiologic and behavioral response.
Many decisions are based on beliefs concerning the likelihood of uncertain events such as the outcome of an election, the guilt of a defendant, or the future value of the dollar. Occasionally, beliefs concerning uncertain events are expressed in numerical form as odds or subjective probabilities. In general, the heuristics are quite useful, but sometimes they lead to severe and systematic errors. The subjective assessment of probability resembles the subjective assessment of physical quantities such as distance or size. These judgments are all based on data of limited validity, which are processed according to heuristic rules. However, the reliance on this rule leads to systematic errors in the estimation of distance. This chapter describes three heuristics that are employed in making judgments under uncertainty. The first is representativeness, which is usually employed when people are asked to judge the probability that an object or event belongs to a class or event. The second is the availability of instances or scenarios, which is often employed when people are asked to assess the frequency of a class or the plausibility of a particular development, and the third is adjustment from an anchor, which is usually employed in numerical prediction when a relevant value is available.
