Stress

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Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.JournalofSurgicalResearch.com

Hot Topic From the 2020 Academic Surgical Congress

Mastering Stress: Mental Skills and Emotional


Regulation for Surgical Performance and Life

Nicholas E. Anton, MS,a,* Carter C. Lebares, MD, FACS,b


Theoklitos Karipidis, MS,c
and Dimitrios Stefanidis, Md, PhD, FACS, FASMBS, FSSHa
a
Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
b
Department of Surgery, University of California San Francisco, San Francisco, California
c
Department of Counseling Psychology, Indiana University School of Education, Bloomington, Indiana

article info abstract

Article history: Mental skills and emotional regulation training are gaining acceptance in surgical educa-
Received 21 August 2020 tion as vital elements of surgeon development. These skills can effectively enhance
Received in revised form technical skill development, improve well-being, and promote career longevity. There is
6 January 2021 evidence emerging in the surgical education literature to support the incorporation of
Accepted 15 January 2021 mental skills and emotional regulation training curricula in residency training. In this
Available online 5 March 2021 study, we present the existing evidence supporting the use of this training with high
performers to reduce stress and optimize well-being and performance. We also consider
Keywords: the recent research emerging in surgical education that offers validity evidence for use of
Mental skills mental skills training with surgeons. Finally, we provide a framework to guide the incor-
Emotional regulation poration of these skills throughout the career of a surgeon and suggest methods to promote
Resilience the development of mental skills training efforts nationally.
Stress ª 2021 Elsevier Inc. All rights reserved.
Performance
Mindfulness

Introduction supporting MST, discuss theory and empirical work regarding


underlying mechanisms, highlight existing evidence-based
Mental skills training (MST) and affective (or emotional) programs that provide basic and specialty-specific applica-
regulation are increasingly recognized as critical components tion of these skills, describe concrete steps for implementa-
of surgeon technical development,1 well-being,2 and profes- tion of such programs, and propose a broader application to
sional longevity.3 Evidence-based curricula now exist for both the field of surgery and health care in general. The purpose of
foundational skill sets and focused application. In this white this study is to clearly define MST (a subject that remains
paper, we will present the scientific background and evidence unnecessarily misunderstood), draw attention to the

This invited white paper was written in conjunction with a Hot Topics symposium presented at the 15th annual meeting of the Ac-
ademic Surgical Congress in Orlando, FL on June 02, 2020.
* Corresponding author. Surgical Skills Coach, Department of Surgery, Indiana University School of Medicine, 702 Rotary Circle, R022b,
Indianapolis, IN 46202. Tel.: 317-274-3164; fax: 317-274-8769.
E-mail address: nanton@iu.edu (N.E. Anton).
0022-4804/$ e see front matter ª 2021 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jss.2021.01.009
A2 j o u r n a l o f s u r g i c a l r e s e a r c h  j u l y 2 0 2 1 ( 2 6 3 ) a 1 ea 1 2

substantial extant evidence supporting the value of MST, and interactions with the environment and assess their relevance
orient surgeons to become leaders in promoting and to well-being (i.e., potentially harmful versus beneficial). Sub-
resourcing these efforts locally and nationally. sequent appraisal determines if adequate abilities and re-
sources exist to avoid harm, and this calculus determines an
individual’s perceived ability to cope. If a situation is
What is stress? appraised as threatening (or simply provocative), stress is
heightened and a cascade of sympathetic nervous system
As surgeons we know the experience of stress well: the rapid (SNS) activation is initiated. The body is mobilized to
heart rate and adrenaline rush of myriad things to do. Yet, respond,18,19 resulting in what we know as the ‘fight or flight’
while familiar, stress remains hard to define. In the modern response.20 Evolutionarily, this reaction is essential to survival
conceptualization, stress is a comprehensive term that re- and in the short term can stimulate adaptation and mastery of
flects increased arousal in response to both positive and new skills. In accordance with the ‘broaden and build’ para-
negative stimuli. Reflecting its heterogeneous and dynamic digm,21 this experience of stress increases an individual’s
nature, stress can be stimulating or toxic and can be caused by sense of capability, enhances their perceived ability to cope,
different things for different people on different days.4,5 In and increases their likelihood of facing future adversity in a
spite of its variable etiology, the initial effect of stress is uni- similarly masterful fashion.22 A key component of ‘broaden
versal and evolutionary: we physically prepare to fight or flee, and build’ recognizes that one’s perception of having
we are compelled by a desire to react, and what we do next is adequate abilities is based on both past performance and
mediated by feedback between the hypothalamic-pituitary- one’s sense of self. This latter point is the domain of mental
adrenal axis and the prefrontal cortex.6 This last point is training and emotional regulation, whereby ability can be
critical because it underscores the reciprocal communication dramatically influenced by positive versus negative self-talk,
that governs the human stress response and clarifies how our mental imagery of success versus failure, and a growth
experience of stress is related to cognition. As such, there is versus a fixed mindset.13,23,24 These principles are founda-
growing awareness that stress can be mediated by cognitive tional to high-performance sports psychology12,24 and sup-
skills, as first evidenced by studies of resilient individuals.7-9 ported by studies in elite women athletes,13 military “soldier
Resilient individuals, often concentrated in high-stress, athletes”,25 and meta-analysis across sports fields.26
high-performance fields, share a common cognitive ten- On the contrary, if stressors are prolonged or over-
dency to perceive stressors as surmountable rather than whelming, an individual’s sense of capability can become
overwhelming events.10 This kind of mental shift is familiar to overtaxed and they can be pushed to the “threat” side of the
surgeons and is exemplified in the scenario of uncontrolled “inverted-U” curve. This decline can be promoted or exacer-
operative bleeding. As medical students, our natural reaction bated by individual factors, such as poor self-perception,27
to a pumping artery is to flinch or freeze, but somewhere in habituated negative self-talk,13 or simply a lack of coping
the process of training, we learn to subvert this reaction and skills.28 Systems’ factors in the form of external resources play
replace it with controlled calm. This represents an adaptive an equally critical role, as evidenced by the deleterious effect
response (a cognitive shift) that can be learned. With rein- of poor social support in studies of job strain and workplace
forcement and practice, such skills can be called on more satisfaction.29 An increasing body of evidence underscores the
readily and as needed. impact of chronic psychosocial stress and describes the
adverse physiologic, cognitive, and affective impact of this
“allostatic load”, particularly when it is prolonged.30-32
Stress and performance

Cultivating the ability to reframe stress has profound impli- Stress and well-being
cations for performance. Decades of empirical work in both
basic science and with top-performing athletes highlights The field of social genomics provides insight into the mecha-
how stress in the right circumstances can stimulate adapta- nism by which chronic or overwhelming stress drives physi-
tion and mastery.11-14 These observations exemplify the ologic deterioration by identifying specific types of human
Yerkes-Dodson law, often referred to as the “inverted-U phe- gene activation patterns associated with adverse social con-
nomenon”, which proposes that increasing stress is beneficial ditions.31,33 The “conserved transcriptional response to
to achieve optimal performance,15 but that beyond this point, adversity”,34 characterized by increased activity of proin-
additional stress results in decline. In an attempt to clarify this flammatory gene transcription pathways (i.e., NFkB and AP-1)
further, Selye (1987) differentiated distress (i.e., that which and decreased activity of the innate antiviral response (e.g.,
negatively affects an individual’s state) from eustress (i.e., type I interferons), is a common pattern of gene transcrip-
that which positively affects an individual’s state), noting that tional alterations that occur with chronic low-grade SNS
these states are largely dependent on an individual’s inter- stimulation such as that found in populations experiencing
pretation and reaction to the stimuli at hand.16 A key question socioeconomic stress, social isolation, or sleep deprivation.30
is what determines this critical interpretation and reaction? This state has been linked to the development of cardiovas-
Indeed, Folkman et al. (1986) describe two primary pro- cular disease,35 Alzheimer’s dementia, and cancer.36,37
cesses, cognitive appraisal and coping, which mediate the Cognitively, profound or chronic SNS activation can
individual-environment stress relationship.17 Cognitive decrease working memory capacity (i.e., the system respon-
appraisal is a process whereby individuals evaluate sible for temporary storage and manipulation of information),
anton et al  mastering stress A3

promote hypervigilance (i.e., inappropriate attention to task-


irrelevant stimuli), and impair decision-making (i.e., Definition of mental skills
decreased executive function, cognitive control, and inten-
tionality in decisions).18,32,38,39 Psychologically, chronic Mental skills refer to a set of psychological techniques
distress dramatically increases the odds of disorders such as designed to support individuals and teams to achieve optimal
burnout, anxiety, suicidality, and depression40 and the odds of levels of performance through skilled management of
concomitant negative coping behaviors such as alcohol stressors inherent to high-stakes endeavors.53 Those skills
abuse.41,42 Interpersonally, burnout (i.e., defined as a sus- have been applied widely in sport psychology and among
tained response to overwhelming work-related stress) is other high-performance populations such as musicians, per-
further associated with strained and dysfunctional relation- forming artists, business professionals, military personnel,
ships including decreased patient satisfaction and impaired and police special forces.53-57 MST is fundamentally divided in
professionalism. two categories: somatic and cognitive interventions. The so-
matic domain involves the use of mindfulness-based in-
terventions (MBIs) to develop situational awareness (of
Impact of stress on surgeon performance internal and external stimuli), emotional response regulation
(to provocative stimuli), and metacognition (the ability to
Surgery is among the most stressful and demanding pro- purposefully call on these skills as needed). The cognitive
fessions one can enter. Surgeons are faced with cognitive, domain involves, but is not limited to, mental imagery, mental
physical, and emotional demands, some of which are inherent rehearsal, refocusing strategies, goal setting, and performance
(stemming from the life and death nature of our work) and mental routines.58 Although the somatic and cognitive in-
some of which are unnecessary (stemming from system-level terventions are presented as separate, they are interrelated
inefficiencies and institutional-level inequities).43 Neverthe- components of human psychosomatic function and reflect
less, individuals accumulate the effect of negative stressors the feedback process between the hypothalamic-pituitary-
regardless of the source, as described previously. For sur- adrenal axis and the prefrontal cortex, which governs the
geons, the sequelae of high stress titers are profound: over- human stress response.
whelming stress is associated with higher prevalence of MST is based on the premise that task mastery and per-
burnout, anxiety, depression, suicidality, and alcohol abuse.42 formance can be enhanced by specifically addressing the
Moreover, surgeons suffering from high levels of burnout are psychological state of the individual,56 improving self-
at higher risk for reduced work capacity and increased attri- knowledge and confidence, and providing discrete tools for
tion from the field,44 with a recent estimated health care the emotional and physical regulation of the stress
expense of $900 million attributed to attrition of surgeons response.59 Hence, MST involves mental and physical skills
under the age of 55 y.13 Ultimately, heightened stress can development that simultaneously enhances performance and
impair surgeons’ performance, which can increase intra- psychological well-being.58,60 Like all other forms of training,
operative errors and compromise patient safety.45,46 mental skills require initial teaching by experts, patient
Nevertheless, surgery is also profoundly gratifying and dedication by learners, and time to train and practice applied
comes with substantial social capital. Surgery residency re- skills. A growing body of evidence demonstrates that this in-
mains highly competitive, drawing prospective applicants vestment pays dividends, arguing that high-performance
from the upper echelons of top institutions and producing fields are remiss in not having an ‘internal curriculum’ of
individuals who are thought leaders in ethics and humanism, this sort to augment traditional intellectual and technical
pioneers in equality and innovation, and champions in global training. A seminal example is the United States military
health. In spite of these achievements, we know that burnout which, in response to a mandate by 2008 Chief of Staff General
is real, attrition and suicide are unacceptably high, and there George W. Casey, Jr, and in collaboration with the University
is a loss of potential and a diminishment of joy that deserve of Pennsylvania, created the Comprehensive Soldier Fitness
redress. Growing international consensus recognizes that this program, a pre-emptive intervention aimed at increasing
situation and its remedy involve three reciprocal domains,47 resilience, psychological well-being, and mental toughness in
necessitating intervention on the level of individuals, sys- soldiers, their families, and civilian personnel.56 This un-
tems, and culture.48-51 The critical point is that changes precedented move was motivated by General Casey’s recog-
among all three are necessary for us to fix our situation. nition of increased psychological and behavioral issues
Surgeons are rightly characterized as highly individual- among soldiers returning from repeated deployment to Iraq
istic, disciplined, oriented toward skills acquisition, and and Afghanistan. He declared that the United States Army was
inspired by the desire to fix what is broken.52 These ten- charged with comprehensively preparing its soldiers for suc-
dencies, in concert with our persistent role as thought and cess yet had historically lacked any formal training for man-
opinion leaders, place us in a unique position to affect change aging the profound inherent stress of active military
in this arena. In the following we will present evidence and duty.28,61,62 Since then, similar training has been integrated in
argument that the incorporation of MST in surgery as a means the recruiting process of special forces, such as the U.S. Navy
for us to intervene on a pressing issue in our midst (i.e., Seals,63 and other high-stress, high-stakes fields such as
overwhelming stress), reinspire a deserved sense of joy in our policing and politics.64,65
work, and galvanize us to identify and direct changes to the In spite of more than a decade of data supporting the
obsolete systems and organizational elements that contribute benefit of this approach, surgery has been slow to incorporate
to this problem. such practices. Nevertheless, the growing body of evidence
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regarding both the need for and efficacy of MST for surgeons nonsurgical trainees and practicing surgeons. Early studies of
confirms the feasibility and value of adopting an ‘internal ESRT among surgery trainees demonstrated feasibility and
surgical curriculum’ to augment traditional intellectual and acceptability as evidenced by the reasonable implementation
technical training.1-3,66,67 cost, low attrition, and high rate of home practice. Further-
more, ESRT was perceived as credible and satisfying, in spite
of the untraditional content and the need for in-person class
Mental skills interventions in surgery and attendance. Skills were readily integrated into participants’
evidence of effectiveness everyday lives.68 Early studies also showed ESRT participants
to have reduced stress, increased working memory capacity,
There have been substantial efforts made to develop mental increased activation of neural substrates associated with ex-
skills and emotional regulation training programs with sur- ecutive cognitive function, emotional regulation, and complex
geons. Because our groups (Departments of Surgery at Uni- bimanual coordination,72 and better performance on laparo-
versity of California, San Francisco (UCSF) and Indiana scopic simulator tasks. More recent work has demonstrated
University (IU)) have published a significant amount of statistically significant benefits to ESRT participants in terms
research on the efficacy of our programs, we will highlight of lower emotional exhaustion, lower depersonalization,
these programs first. We will then briefly highlight other higher mindfulness, and higher global executive cognitive
programs designed to implement mental skills and emotional function both postintervention and at long-term follow-up.
regulation skills in surgery. Moreover, ESRT participants showed statistically significant
At UCSF, our group has developed enhanced stress resil- mitigation of a stress-activated proinflammatory gene
ience training (ESRT) which is a streamlined and tailored MBI expression profile (conserved transcriptional response to
loosely based on John Kabat-Zinn’s mindfulness-based stress adversity), as compared with controls.2 With the onset of the
reduction, the most scientifically vetted MBI to date.68 The COVID-19 pandemic, ESRT was modified for remote delivery
core components of ESRT focus on the development of three and was successfully provided to practicing surgeons at 10
key cognitive skills: interoception (i.e., moment-to-moment academic sites, across all four US time zones, and to individ-
situational awareness of thoughts, emotions, and sensa- ual surgeons in the military. In 2020, for the first time, ESRT is
tions),69 emotional regulation (i.e., development of non- part of the mandatory educational curriculum for incoming
reactivity in response to internal and external stimuli),70 and UCSF residents in surgery and obstetrics and gynecology.
metacognition (i.e., conscious awareness of one’s cognitive At IU, a novel mental skills curriculum (MSC) designed to
control processes).71 These skills are taught through experi- reduce stress and enhance the performance of surgery resi-
ential training in various mindfulness practices (focused dents has been developed and implemented. This MSC con-
breathing, body scan, qi gong) and scaffolded onto a concep- sists of eight modules (outlined in Table 2) and was developed
tual framework explaining their relationship to cognitive by a multidisciplinary team of a surgeon educator, a PhD
training, emotional regulation, and behavior change for the educator with industrial design expertise, and a performance
purpose of enhancing stress resilience in physicians. Criti- psychologist with expertise in MST.73 The modules are
cally, there is an emphasis on bringing these skills into sur- implemented with residents in weekly sessions and feature
geons’ daily lives through informal (i.e., ‘‘throughout the day’’) video education and didactics with a trained mental skills
practice and explicit contextualization of skills to the personal coach, workbook exercises for immediate practice of learned
and professional circumstances of surgeons.2 skills, and applied practice of surgical skills during simulation
For example, using emotion regulation techniques in training. We have accumulated evidence of effectiveness for
difficult communication with other health care workers, this curriculum through the conduct of numerous studies. We
mindful walking during rounds, breathing techniques to have shown that novices significantly improved their laparo-
dispel stress and reclaim attention in the operating room (OR), scopic surgical skills and mental skills use73 and experienced
and using metacognitive skills to transition out of work and significantly lower stress during two validated stress tests
enjoy personal time more fully. The goal of this applied after training with this curriculum.74 We have also shown that
practice is to explicitly mitigate the most common and this curriculum enhances skill transfer from the simulated
recurring sources of surgeons’ stress and emphasize the environment to the clinical environment75 by minimizing the
pragmatic importance of integrating mindfulness practices typical skill deterioration that is observed during this transi-
within daily life. The course comprises five 1-h classes with a tion.76 In a randomized-controlled trial with surgical novices,
focus on experiential practice, not intellectual content we found that MSC-trained novices demonstrated higher
(Table 1). A progressive amount of daily home practice is laparoscopic skill retention 2 months after training compared
assigned, and a voluntary group meditative hike (2-3 h out- with controls.77 Importantly, our group implemented our MSC
doors) is held after week 3 or 4. The ESRT curriculum bundle with surgery residents in a multisite, randomized-controlled
involves an online platform of short videos which deliver the trial of its effectiveness.1 After stratification of residents into
conceptual framework, an app-based platform of guided training conditions (i.e., MSC and controls), both groups were
meditation recordings to support daily home practice, and a trained in laparoscopic skills and asked to participate in a
facilitators’ guide (detailed manual) to support transfer test on a porcine Nissen model. Residents were asked
implementation. to perform under normal and stressful conditions where
Since its inception, in 2016, ESRT has been studied in two stressors (e.g., interruptions, technical challenges, poor
single-institution randomized controlled trials, of a total of 65 assistance, etc.) were introduced by the study team. We found
first-year surgery trainees, and several cohort studies of that in spite of both groups performing comparably under
anton et al  mastering stress A5

Table 1 e Practical and conceptual differences: traditional MBSR, ESRT-beta, and final ESRT.
Modification Traditional MBSR ESRT-beta Purpose of Final ESRT Purpose of
modification modification
Practical
Class number 9 wk 6wk (L) to utilize 6-wk 5 wk (C) further
Intro session þ 8 wks summer gap in didactics minimize clinical
disruption
Class duration 2.5 h 1.5 h (L) provide protected 1h (L, C) to enhance
Emergent, Focused time, while preserving Explicit, short video- acceptability and
metaphorical, discussions 80h work-week, based conceptual accessibility
breaks, didactics and didactics, educational and OR time content
no break
Retreat 8h silent sitting 3h ‘Medi Hike’, (C) request for fresh air No change
retreat, off-site outdoors and exercise
meditation center
Assigned daily 45 min daily 20 min daily (C) responsive to time- Goal is consistency, (C) ‘failing’ at
practice time compressed surgical ideal is 20 min, 20 min, added to
lifestyle emphasis on informal participant stress
(“all day long”) practice (Type A personality)
Conceptual
Class content 1.5 hdmeditation 1hdmeditation (L) preserve experiential 45-50 mindmeditation (C) capitalize on
1hdsharing, stories, 30 mindless focus, shorten class time 10-15 mindexplicit culture of skills
Meandering sharing, more concepts training, fast
approach focused learners
approach
Emphasis Insight, life-long Skill set for (C) application to life, Resilience skill set, (C) growing
learning about self, stress relationships, training, specific work distress and
world. Broad health resilience, in career longevity application, cognitive burnout,
enhancement. general training. modeling ESRT in
work, life.
Contextualization Broad application of Application to (C) skills applied to Emphasize applied (C) explicit skills
concepts, awareness personal and surgeons’ life and work techniques, all day, for explicit
to all interactions professional various scenarios situations, clear
situations mental model
Expectation Committed formal Daily practice (C) reinforce ‘some is Train formally, but ‘live (C) capitalize on
practice mostly formal, better than none at all’ your practice’. Informal natural tendency
less informal practice, anywhere, all for repetition and
day ritual

(L) ¼ logistical modification; (C) ¼ cultural modification; MBSR ¼ mindfulness-based stress reduction; ESRT-beta ¼ enhanced stress resilience
training early version, 6 wk, 1.5-h classes, 20 min/d home practice; ESRT-Final ¼ enhanced stress resilience training final postiterative version, 5
wk, 60-min classes, progressive amount of daily formal practice, heavily emphasized informal practice.

normal conditions, MSC-trained residents were able to pre- enhancing skill acquisition and surgical performance,
serve their surgical skill significantly better than controls increasing confidence, knowledge, teamwork, and reducing
under stressful conditions. stress. There have also been efforts in surgical education to
Thus, our studies demonstrate that the IU MSC is effective implement stress-resilience training to improve surgeon
in increasing mental skills of participants, enhancing their well-being. Riall et al. (2017) have developed the “Energy
surgical skill acquisition and retention, and minimizing per- Leadership Well-Being and Resiliency Program” for surgeons,
formance deterioration under stressful conditions in the OR. which is a curriculum designed to address the mental, social,
Given these findings, this curriculum has been incorporated and physical elements of surgery residents’ well-being.3
into our surgery residency curriculum to benefit all our During monthly sessions, residents are taught skills related
trainees. to goal setting, mindfulness, team building, communication,
There have been efforts beyond our groups to implement work-life balance, empathy, diet and exercise strategies,
mindfulness-based stress reduction and mental skills in- mindfulness of ergonomics, and stress management tech-
terventions in surgical education that warrant mention as niques. The authors found that their program improved
well. In a recent review of mental skills interventions in residents’ exhaustion, life satisfaction, perceived stress,
surgery, we found that before 2017, 19 studies had been emotional intelligence, and overall perception of the resi-
conducted to assess the benefit of mental skills (i.e., primarily dency program. Residents reported that they were able to
mental imagery) for surgical novices and trainees.78 Results incorporate these skills into their daily work and personal
indicate that these interventions are highly effective for lives, which provides further evidence that regular practice of
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Table 2 e Indiana University mental skills curriculum.


# Module Description Goals and objectives
0 Overview and Overview of mental skills training The goal of this session will be to introduce the learner
introduction to to the curriculum and reinforce the need for mental
MSC skills training in surgical practice. By participating in
this session, the learner will.
 briefly describe the history of mental skills training
(MST)
 report the rationale for MST in medicine
 describe the process of the MSC
1 The science of Overview of the science of neurology and how it relates  The goal of this session will be to continue to intro-
attention, focus, to the skills in this curriculum duce the learner to the curriculum and teach them the
and concentration neurological science behind attention, focus, and
concentration. By participating in this session, the
learner will.describe the differences between
bottom-up and top-down neurological processes
 review Nideffer’s attentional model of performance
excellence
2 Goal setting Role of clear, effective goals in achieving performance The goal of this session will be to equip the learner with
excellence and building confidence; importance of the knowledge and skills to establish clear and effective
clarifying both the tasks and processes essential for performance goals. By participating in this session, the
success in a procedure; includes learner will.
 technical (e.g., nodal points; clear performance plan)  define and differentiate between outcome, perfor-
 process (e.g., slow and steady; breathe to remain mance, and process goals
calm; optimal team behavior)  identify characteristics of his or her ideal performance
state
 set technical goals for a procedure (for example,
identify 2-3 nodal points of a procedure)
 identify process goals for a procedure (e.g., staying
calm, confident, and relaxed; optimal team behavior)
3 Activation Skills to relax physically and mentally, as well as The goal of this session will be to equip the learner with
management techniques for raising energy level when fatigued the knowledge and skills to manage physical and mental
states. By participating in this session, the learner will.
 demonstrate breathing and attention techniques to
achieve greater states of physical and mental calm.
(Sample outcome: Reduce heart rate six beats in 12 s)
 demonstrate techniques to raise physiological acti-
vation and attention. (Sample outcome: Raise HR six
beats in 12 s)
4 Attention Techniques for maintaining attention on what is The goal of this session will be to equip the learner with
management essential and ignoring distractions the knowledge and skills to effectively maintain
 thought stopping attention. By participating in this session, the learner
 self-talk will.
 redirecting attention  identify personal negative self-talk in performance
situations and effective strategies for managing self-
talk
 demonstrate ability to redirect attention from a
distraction to a target behavior
5 Imagery Techniques for mental rehearsal of both technical The goal of this session will be to equip the learner with
aspects and nontechnical skills (e.g., managing the knowledge and skills to effectively mentally
emotions; successfully dealing with stressful events) rehearse. By participating in this session, the learner
will.
 identify strategies for maximizing effective use of
imagery and mental rehearsal
 incorporate imagery into practice and performance
situations
6 Refocusing Techniques and principles for handling various events The goal of this session will be to equip the learner with
strategies that can be stress inducing or disruptive; learning how the knowledge and skills to confront challenging events
to develop specific, individualized strategies for coping; in the OR. By participating in this session, the learner
plans address both technical and nontechnical aspects will.
of situation, including team interactions  identify events which are particularly stress inducing
or distracting to the surgeon
 devise personalized and specific strategies for man-
aging these situations
(continued)
anton et al  mastering stress A7

Table 2 e (continued )
# Module Description Goals and objectives
7 Preoperative Techniques and principles to ensure that one is The goal of this session will be to equip the learner with
mental routines mentally ready to perform, as well as physically and the knowledge and skills to develop preperformance
technically ready; includes preparation for both the mental routines. By participating in this session, the
initiation of a procedure and resuming after a break or learner will.
loss of focus  develop a clear preperformance “mental readiness”
routine for OR performance

mindfulness and mental skills provides beneficial down- deterred by the time required to learn these skills. Trainees
stream effects. perceive these programs as valuable to their performance and
well-being,68,73 when they are framed as skills with evidence-
based roots. The question becomes, how can leaders imple-
Common characteristics of existing programs ment similar programs in their own residency programs?

A number of common elements are found in available mental


skill and mindfulness/emotional regulation training programs
that are worth exploring. First, is the use of cognitive training Challenges and recommendations for
to notice stress and address it through learned skills. Across implementation
interventions, we see effectively lowered stress and anxiety
and (where assayed) improved performance in challenging In a study on the barriers and enablers to adoption of ESRT
situations. In some instances, these benefits are operative, but and factors contributing to sustainability, the group at UCSF
in others instances, benefits are seen in challenging inter- performed a thematic analysis of interview data with
personal or even intrapersonal situations. In addition, both departmental leadership and administrators across multiple
MSC and ESRT have shown benefits to executive function, disciplines.79 The researchers found several key factors
which suggests that the performance benefits we see are not contributed to adoption and sustainability of ESRT, including
one-offs, but rather the result of more central cognitive culture (i.e., establishing value, knowledge of evidence, and
changes. Finally, across interventions, we see benefits to well- personal experience), infrastructure to mitigate barriers (i.e.,
being in the form of greater self-confidence intraoperatively, time barriers, service coverage, and allowance), and adapt-
less vulnerability to burnout, and/or a stronger sense of being ability in the training program to suit the need of individuals
balanced in one’s life. These findings support the assertion (i.e., aligning with local culture, ensuring the content is prac-
that mental skills/emotional regulation training yields tical, and tailoring the program to be relevant for individual
tangible benefits that can been seen and applied in multiple needs).
contexts. This speaks to the longitudinal relevance and In an effort to determine how these influential themes
versatility of such skills that can be applied across the breadth could be generalized to support sustained program imple-
and trajectory of a surgeon’s life. Although MST is not meant mentation, themes were compared with the consolidated
to replace technical and didactic surgical training, it can framework for implementation research (Table 3). The
effectively be used as a synergistic adjunct. Nevertheless, consolidated framework for implementation research can be
similar to technical and cognitive skills, all versions of MST utilized to clarify factors that impact what aspects of an
require dedicated practice time outside the OR. intervention work, why they work, and how to guide imple-
Second, evidence suggests that deliberate practice of mentation efforts based on these data.80 In the following we
mental skills is needed to obtain maximal benefits. In those outline a few key factors that are universally valuable to
programs that feature comprehensive skills training over time advancing the uptake of MST, institutionally.
and assimilation into daily habits with in-class and outside First, we acknowledge that all educators involved in
practice, there are clear longitudinal benefits. Thus, educators improving the training and experience of surgical trainees are
seeking to implement MST with trainees should view mental ultimately targeting the same outcome. We all aim to equip
skills much like technical skills; deliberate practice can facil- learners with the skills necessary to be the most effective
itate mastery and “muscle memory” during stressful situa- surgeons possible in spite of variable conditions inside and
tions that impair one’s ability to make conscious decisions, as outside of the OR, to achieve and maintain fulfillment and joy
practice will enable trainees to automatically utilize stress in their work, and to maintain and possibly enhance well-
coping skills to manage their activation and focus on the task being throughout their careers. These goals are not exclusive
at hand. to the select mental skills and ESRT programs outlined pre-
The third common component of these programs is that viously; rather, there are similar local efforts in residency
they have all focused on training residents in the context and programs across the world. The local champions of these ef-
constraints of real life, clearly showing that implementation forts should be lauded for their often pioneering and under-
of formal mental skills and ESRT programs is feasible and appreciated work to disseminate these needed skills to their
effective despite the limitations on resident duty hours. Edu- resident charges. However, we contend that our field should
cators interested in applying MST with residents should not be transition to a more comprehensive and systematic approach
A8 j o u r n a l o f s u r g i c a l r e s e a r c h  j u l y 2 0 2 1 ( 2 6 3 ) a 1 ea 1 2

Table 3 e Mapping of influential factors to CFIR constructs and domains.


Influential factors Consolidated framework for implementation research (CFIR)

Theme Subtheme CFIR construct CFIR domain


Culture Establishing value Intervention source Intervention characteristics
Design quality and packaging Outer setting
Cost Inner setting
Patient needs and resources Characteristics of individuals
Culture Process of implementation
Implementation climate
Planning, reflecting, and evaluating
Knowledge of evidence Evidence strength and quality
Networks and communications
Knowledge/beliefs about intervention
Personal experience Relative advantage
Trialability
Peer pressure
Culture, self-efficacy/stage of change
Knowledge/beliefs about intervention
Engaging
Infrastructure Time Complexity Intervention characteristics
Design quality and packaging Outer setting
Implementation climate Inner setting
Planning, executing Characteristics of individuals
Process of implementation
Protection Cost
External policies and incentives
Networks and communications
Culture
Implementation climate
Planning, reflecting, and evaluating
Allowance Cost
Peer pressure
Structural characteristics
Networks and communications
Culture
Implementation climate
Knowledge, beliefs about intervention
Adaptability Identification Design quality and packaging Intervention characteristics
Culture, self-efficacy Outer setting
Knowledge, beliefs about intervention Inner setting
Identification with organization Characteristics of individuals
Engaging Process of implementation
Practicality Adaptability
Structural characteristics
Implementation climate
Self-efficacy
Planning, executing
Relevance Patient needs and resources
Culture, self-efficacy/stage of change
Knowledge, beliefs about intervention
Engaging

to MST, much like the use of TeamSTEPPS to disseminate Basic training


skills to enhance teamwork with medical professionals.81 The implementation of mental skills and ESRT should ideally
begin with an introduction of concepts and education about
A conceptual framework for MST in surgery the mind-body connection that defines performance and well-
being. Specifically, it is important to clearly delineate the
We propose the following framework to conceptualize the impact of positive and negative thinking on psychophysio-
evolution and applicability of mental skills in surgical training logical functioning. It is also important to help learners define
and beyond (Figure). their ideal performance state (IPS) (i.e., psychological and
anton et al  mastering stress A9

which could further develop their mental skills repertoires to


manage unforeseen challenges in the future. Ultimately, we
believe this approach will allow residents to build their skill
set effectively and work toward independence, growth, and
improved well-being.

Preparing for independence


Throughout their advancement in residency training, surgery
residents are afforded greater autonomy in training that al-
lows them to perform surgical procedures and manage patient
care with more passive supervision from faculty.83 However,
increased autonomy exposes surgery residents to numerous
challenges that attendings face on a regular basis (e.g., tech-
nical complications, aberrant anatomy, frustration and doubt
about skill, managing difficult patients or families) that
require robust mental abilities to overcome. Although resi-
dents are expected to learn these skills serendipitously, we
believe mental skills that are developed through basic training
and embodied learning can better prepare senior residents to
face this transition to independent surgical practice including
after they leave residency. Through the adaptation and
Fig e Conceptualization of mental skills in surgical refinement of learned mental skills throughout training, res-
training. (Color version of the figure is available online.) idents can learn to apply these techniques to manage their
psychological response to complications or extremely difficult
procedures and maintain appropriate confidence in their
physiological) in various performance contexts before they abilities.
move into learning specific skills. As described in previous
sections, eustress can be beneficial to performance if it pro- Systems’ improvement
motes an individual’s IPS, so helping learners identify the Ultimately, the expected downstream effects of residents’
boundaries of their own IPS can enable them to realize when learning mental skills and ESRT will be their adaptability to
activation management is necessary. Moreover, during basic varying clinical situations that help them mitigate errors,
training, individuals should be exposed to fundamental ensure patient safety, and maintain their personal well-being
techniques (e.g., breathing, relaxation, mindfulness) to when they enter practice. Estimates of costs incurred to hos-
familiarize themselves with the process. pital systems as a result of surgical complications indicate
that costs increase by up to five times when complications
Embodied learning occur after surgery.84 Through the use of mental skills to help
The concepts and skills taught during basic training should be mitigate preventable intraoperative errors, surgeons can
embodied by residents as habits for surgical performance. avoid significant costs being incurred on hospital systems.
Much like technical skills, deliberate practice of mental skills Furthermore, a recent cost-consequence analysis of physician
is necessary for the maturation of those skills. For example, burnout in the United States revealed that physician turnover
residents might use mental imagery to improve their laparo- and reduced clinical hours cost approximately $4.6 billion
scopic suturing ability, which would require them to engage in each year. Given the evidence of ESRT to increase physician
an iterative process of practicing imagery, then physically well-being,2 physicians trained in ESRT may experience lower
suturing in the low-pressure environment of simulation, then burnout, and as a result, stave off career change or a reduction
refining their imagery experience by including newly learned in clinical hours. Thus, mental skills and ESRT programs could
suturing techniques. Through deliberate practice, residents save hospital systems’ significant costs over time.
would be able to develop more vivid and accurate mental On an individual level, surgeons trained in these tech-
representation of suturing, while simultaneously enhancing niques may be able to apply them to other important aspects
their technical skills. Once skills and confidence in their use of surgery practice including leading others effectively (e.g.,
are developed in the low-pressure simulation environment, colleagues, trainees, and staff), demonstrating enhanced
residents should then seek opportunities to transfer these teamwork, and contributing to system level process im-
techniques clinically. provements. Recent research in the effect of mindfulness
Our suggested application of mental skills is based on training on interpersonal relationships and leader-follower
Fredrickson’s (2004) broaden and build theory which states relationships at work found that leaders’ mindfulness use
that positive emotions “broaden peoples’ momentary had a positive relationship with followers’ satisfaction,
thoughteaction repertoires and build their enduring personal particularly leaders’ communication with their followers.85
resources”.82 We contend that the positive experiences and Thus, it is possible that surgeons trained in mindfulness
emotions derived from mental skill development in low- techniques could enhance the satisfaction of colleagues and
stakes environments could promote joy and interest for resi- patients at their institution, which could further benefit hos-
dents to continue to practice these skills on their own time, pital systems.
A10 j o u r n a l o f s u r g i c a l r e s e a r c h  j u l y 2 0 2 1 ( 2 6 3 ) a 1 ea 1 2

implementation of mental skills training programs in surgery.


Moving forward We have reviewed the structure and content of available in-
terventions and summarized the existing evidence of their
Research priorities effectiveness. Furthermore, we have identified barriers and
implementation strategies for these interventions and are
Ongoing rigorous scientific study of mental skills and ESRT proposing a conceptual framework for their structure. We
programs is paramount to define the most important compo- advocate for the development of mental skills curricula on a
nents and combination of training approaches. We propose national level and propose research priorities to advance the
that Kirkpatrick’s four-level model of training evaluation field. Ultimately, these programs are expected to enhance
should be used to for the effectiveness of mental skills training surgeon skills, improve the outcomes of their patients, and
programs moving forward.86 The four levels of this program promote their effective leadership in the health care system
include evaluation of learner reactions (level one), evaluation of while preserving their well-being.
learning outcomes (level two), evaluation of occupational per-
formance changes due to the intervention (level three), and
evaluation of the larger benefits of interventions on organiza-
tional goals and objectives (level four). To this point, research Acknowledgment
efforts in our field have primarily studied the effects of mental
skills and ESRT programs on the first three levels of the Kirk- Authors’ contribution: N.E.A. and C.C.L. should be considered
patrick scale albeit with few level-three studies having been co-first authors, as they both equally wrote and edited a sig-
performed. Moving forward, research should expand on the nificant amount of this manuscript. T.K. assisted in writing
impact of mental skills interventions on learner clinical per- and editing this manuscript. The senior author for this
formance (level 3 outcomes) and establish the broader manuscript, D.S., provided oversight and edited the group’s
systems-level impact of mental skills interventions such as work on this manuscript throughout its development.
physician retention and burn out rates, patient complication
rates, and follower and patient satisfaction (level 4 outcomes). Disclosure
Research efforts should also focus on studying the longitudinal
effects of these programs on learners’ performance and well- The authors reported no proprietary or commercial interest in
being. We hypothesize that there is a dose-response effect of any product mentioned or concept discussed in this article.
mental skills training on these outcomes, but as of now, the
available evidence is limited. Finally, to ensure that the benefits references
of mental skills and ESRT programs are replicable, there is a
need for multi-institutional projects to study the generaliz-
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