Insights
Mental practice in surgical training Paul Mick1, Anali Dadgostar2, Chris Ndoleriire3, Jane Lea1, Matthew Clark4 and Brian Westerberg1 1
Department of Surgery, University of British Columbia, Vancouver, Canada Department of Surgery, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada 3 Department of Otolaryngology, College of Health Sciences, Makerere University, Kampala, Uganda 4 Department of Otolaryngology – Head and Neck Surgery, Gloucestershire Royal Hospital, Cheltenham, UK 2
M
ental practice (MP) is ‘the symbolic, covert, mental rehearsal of a task in the absence of actual, physical rehearsal’.1 When a musician thinks through a passage or an athlete prepares for competition by visualising their performance, they are engaging in MP. It is a specific form of mental preparation, separate from positive imagery, self-efficacy statements, motivational strategies or attention-focusing. MP has been studied extensively in sports and psychology literature, and is an integral part of the formal training of many individuals who perform complex motor skills at high levels. Although many surgeons and surgical trainees undoubtedly use forms of MP to prepare for cases, it has only recently been investigated as a
formal teaching tool, and to our knowledge is not incorporated into most residency programme curricula. MP, as described in the surgical literature, typically involves a period of relaxation exercises followed by an expert educator reciting a mental imagery script outlining a step-by-step operative approach, with emphasis on visual, haptic and cognitive cues.2 In practice, once a certain level of competency is obtained, it could be performed independently. Based on our experiences as learners and teachers we believe that MP offers a number of potential benefits for surgeons at all levels of training. Motor skills, such as tissue handling, hand–eye coordination and instrument use might best
be learned via physical practice on live patients, cadaveric dissection or simulators. Opportunities for physical practice, however, are increasingly diminished by financial constraints, competition from other trainees, an everexpanding number of procedures to learn or work-to-rule requirements.3 MP may augment physical practice in improving the accuracy and precision of surgical movements.2 Imagining how a movement looks, feels and affects a patient may strengthen cortical representations of the task formed by previous physical practice, or may prime specific neuromuscular pathways.1 The effect of MP on physical skills might thus depend on surgeon experience as novice surgeons might find it difficult to imagine
[Mental Practice] is an integral part of the formal training of many individuals who perform complex motor skills
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–2 1
MP appears to be an excellent method for learning cognitive tasks, regardless of expertise
performing steps of an operation that they have rarely seen or executed.4 More senior surgeons returning to work after a leave of absence or performing a rare operation may benefit most from MP in terms of motor skill improvement. Nevertheless, MP has been shown to improve physical skills at all levels of training, perhaps because the mind is able to imagine what it has never or has infrequently experienced.1 Performing surgery is more of a cognitive than physical task, requiring constant decision making based on ever-changing circumstances. Competent surgeons must plan the steps of the procedure, think ahead, create mental images of anatomy, anticipate danger, know why and when to use specific instruments, understand consequences of actions, organise assistants, teach, and deal with internal and external pressures. MP appears to be an excellent method for learning cognitive tasks, regardless of expertise.1 Cognitive skills may be inadequately taught in the operating room. In our experience, most surgeons never manage an operation from start to finish until their first case of independent practice. The attending doctor makes most of the decisions and judgements, and the trainee can simply follow instructions without much thought. MP, like simulation, allows trainees to plan cases, consider choices, make decisions and ponder outcomes in a safe
manner. Doing so may increase their consciousness of the sometimes unspoken choices being made by their instructors during live cases, and improve their situational awareness in the operating room. Mental practice (MP) techniques focus on mental imagery rather than the verbal representations of surgery that are found in most textbooks. Psychologists studying the dual coding theory of learning (imagery versus semantic learning) have demonstrated that memories are retrieved faster and with less effort when they are coded in the format needed for a task.5 To illustrate the point, think of how easy it is to picture how to tie a shoelace, but how difficult it is to describe the process in words. As with tying a shoelace, surgery is visual and tactile rather than abstract. We would expect that remembering and using stored mental images of an operation would be more efficient and accurate than mentally converting memorised text describing the same procedure into the images, feelings and movements needed to correctly complete the task. We developed an MP script for tympanoplasty that was used to instruct Ugandan otolaryngology residents. The approach was particularly useful in Uganda because of the low cost. Three senior otologists developed a step-by-step script, focusing on important visual and haptic
cues, proper instrument use and how to perform the movements needed to complete the operation. Prior to each tympanoplasty, the attending surgeon guided their resident through the script, a process that took approximately 30 minutes. The scripts were relatively easy to develop and implement, and postoperative surveys indicate that the residents liked the exercise, leading us to believe that MP could be a valuable teaching tool for procedures in a wide variety of clinical settings. REFERENCES 1.
Driskell JE, Copper C, Moran M. Does mental practice enhance performance? Journal of Applied Psychology 1994;79:481–492.
2.
Louridas M, Bonrath EM, Sinclair DA, Dedy NJ, Grantcharov TP. Randomized clinical trial to evaluate mental practice in enhancing advanced laparoscopic surgical performance. Br J Surg 2015;102:37–44.
3.
Accreditation Council for Graduate Medical Education. Work Hour Restrictions 2011. Available at http://www.acgme. org/acgmeweb/tabid/271/ GraduateMedicalEducation/ DutyHours.aspx. Accessed on 2 February 2015.
4.
Wohldmann E, Healy A, Bourne L. Pushing the limits of imagination: Mental practice for learning sequences. Journal of Experimental Psychology: Human Learning and Memory 2007;33:254–261.
5.
Paivio A. Imagery and verbal processes. New York: Holt, Rinehart, and Winston; 1971.
Corresponding author’s contact details: Dr Paul Mick, Department of Surgery, University of British Columbia, Kelowna, Vancouver, British Columbia, Canada. E-mail: [email protected]
Funding: This study was supported in part by a grant awarded by the Branch for International Surgery at the University of British Columbia. Conflict of interest: None. Acknowledgements: None. Ethical approval: Ethical approval for the study was granted by the Clinical Research Ethics Board at the University of British Columbia and the Institutional Review Board at Makerere University. doi: 10.1111/tct.12412
2 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–2
Mental practice in surgical training Paul Mick1, Anali Dadgostar2, Chris Ndoleriire3, Jane Lea1, Matthew Clark4 and Brian Westerberg1 1
Department of Surgery, University of British Columbia, Vancouver, Canada Department of Surgery, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada 3 Department of Otolaryngology, College of Health Sciences, Makerere University, Kampala, Uganda 4 Department of Otolaryngology – Head and Neck Surgery, Gloucestershire Royal Hospital, Cheltenham, UK 2
M
ental practice (MP) is ‘the symbolic, covert, mental rehearsal of a task in the absence of actual, physical rehearsal’.1 When a musician thinks through a passage or an athlete prepares for competition by visualising their performance, they are engaging in MP. It is a specific form of mental preparation, separate from positive imagery, self-efficacy statements, motivational strategies or attention-focusing. MP has been studied extensively in sports and psychology literature, and is an integral part of the formal training of many individuals who perform complex motor skills at high levels. Although many surgeons and surgical trainees undoubtedly use forms of MP to prepare for cases, it has only recently been investigated as a
formal teaching tool, and to our knowledge is not incorporated into most residency programme curricula. MP, as described in the surgical literature, typically involves a period of relaxation exercises followed by an expert educator reciting a mental imagery script outlining a step-by-step operative approach, with emphasis on visual, haptic and cognitive cues.2 In practice, once a certain level of competency is obtained, it could be performed independently. Based on our experiences as learners and teachers we believe that MP offers a number of potential benefits for surgeons at all levels of training. Motor skills, such as tissue handling, hand–eye coordination and instrument use might best
be learned via physical practice on live patients, cadaveric dissection or simulators. Opportunities for physical practice, however, are increasingly diminished by financial constraints, competition from other trainees, an everexpanding number of procedures to learn or work-to-rule requirements.3 MP may augment physical practice in improving the accuracy and precision of surgical movements.2 Imagining how a movement looks, feels and affects a patient may strengthen cortical representations of the task formed by previous physical practice, or may prime specific neuromuscular pathways.1 The effect of MP on physical skills might thus depend on surgeon experience as novice surgeons might find it difficult to imagine
[Mental Practice] is an integral part of the formal training of many individuals who perform complex motor skills
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–2 1
MP appears to be an excellent method for learning cognitive tasks, regardless of expertise
performing steps of an operation that they have rarely seen or executed.4 More senior surgeons returning to work after a leave of absence or performing a rare operation may benefit most from MP in terms of motor skill improvement. Nevertheless, MP has been shown to improve physical skills at all levels of training, perhaps because the mind is able to imagine what it has never or has infrequently experienced.1 Performing surgery is more of a cognitive than physical task, requiring constant decision making based on ever-changing circumstances. Competent surgeons must plan the steps of the procedure, think ahead, create mental images of anatomy, anticipate danger, know why and when to use specific instruments, understand consequences of actions, organise assistants, teach, and deal with internal and external pressures. MP appears to be an excellent method for learning cognitive tasks, regardless of expertise.1 Cognitive skills may be inadequately taught in the operating room. In our experience, most surgeons never manage an operation from start to finish until their first case of independent practice. The attending doctor makes most of the decisions and judgements, and the trainee can simply follow instructions without much thought. MP, like simulation, allows trainees to plan cases, consider choices, make decisions and ponder outcomes in a safe
manner. Doing so may increase their consciousness of the sometimes unspoken choices being made by their instructors during live cases, and improve their situational awareness in the operating room. Mental practice (MP) techniques focus on mental imagery rather than the verbal representations of surgery that are found in most textbooks. Psychologists studying the dual coding theory of learning (imagery versus semantic learning) have demonstrated that memories are retrieved faster and with less effort when they are coded in the format needed for a task.5 To illustrate the point, think of how easy it is to picture how to tie a shoelace, but how difficult it is to describe the process in words. As with tying a shoelace, surgery is visual and tactile rather than abstract. We would expect that remembering and using stored mental images of an operation would be more efficient and accurate than mentally converting memorised text describing the same procedure into the images, feelings and movements needed to correctly complete the task. We developed an MP script for tympanoplasty that was used to instruct Ugandan otolaryngology residents. The approach was particularly useful in Uganda because of the low cost. Three senior otologists developed a step-by-step script, focusing on important visual and haptic
cues, proper instrument use and how to perform the movements needed to complete the operation. Prior to each tympanoplasty, the attending surgeon guided their resident through the script, a process that took approximately 30 minutes. The scripts were relatively easy to develop and implement, and postoperative surveys indicate that the residents liked the exercise, leading us to believe that MP could be a valuable teaching tool for procedures in a wide variety of clinical settings. REFERENCES 1.
Driskell JE, Copper C, Moran M. Does mental practice enhance performance? Journal of Applied Psychology 1994;79:481–492.
2.
Louridas M, Bonrath EM, Sinclair DA, Dedy NJ, Grantcharov TP. Randomized clinical trial to evaluate mental practice in enhancing advanced laparoscopic surgical performance. Br J Surg 2015;102:37–44.
3.
Accreditation Council for Graduate Medical Education. Work Hour Restrictions 2011. Available at http://www.acgme. org/acgmeweb/tabid/271/ GraduateMedicalEducation/ DutyHours.aspx. Accessed on 2 February 2015.
4.
Wohldmann E, Healy A, Bourne L. Pushing the limits of imagination: Mental practice for learning sequences. Journal of Experimental Psychology: Human Learning and Memory 2007;33:254–261.
5.
Paivio A. Imagery and verbal processes. New York: Holt, Rinehart, and Winston; 1971.
Corresponding author’s contact details: Dr Paul Mick, Department of Surgery, University of British Columbia, Kelowna, Vancouver, British Columbia, Canada. E-mail: [email protected]
Funding: This study was supported in part by a grant awarded by the Branch for International Surgery at the University of British Columbia. Conflict of interest: None. Acknowledgements: None. Ethical approval: Ethical approval for the study was granted by the Clinical Research Ethics Board at the University of British Columbia and the Institutional Review Board at Makerere University. doi: 10.1111/tct.12412
2 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–2
