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The Cutting Edge:  Performance Psychology with Surgeons*

Charlie Brown, Ph.D.
Director, Get Your Head In The Game

Imagine your emotional reactions to the following scenarios.  Scenario 1 – Your basketball team is down by one point with 45 seconds to play; but you have the ball after a time out and you know that every player on your team averages 53% from the field.  Pause and consider your assessment and emotional response.   Scenario 2 – It is the bottom of the ninth inning of a tie baseball game.  The bases are loaded and your next batter has been hitting .400 this season.   Again pause and consider your assessment and emotional response.  Scenario 3 – You are preparing to undergo heart surgery, and you learn that the surgery team has a 53% success rate.  Consider your assessment and emotional response.   Consider the contrast: if a baseball player has a .400 average we would put him in the Hall of Fame; a surgeon with a .400 average would probably be put in jail.

When appraising non-athletic settings where excellence in mental and physical performance is required on a routine basis, few situations can compare with that of the practice of medicine, and particularly of surgery.   Surgeons are consistently asked to perform complex tasks involving cognitive decisions, concentration, and fine motor skills, often in chaotic multi-tasking situations, with minimal margin of error.  Athletes often calm themselves by reflecting, “Hey, it’s just a game; it is not a matter or life or death!” Surgeons cannot.

Surgeons have historically accomplished these demands without the benefit of formal mental skills training.  For the performance psychologist, this raises several questions:  How do they do it?  Can the knowledge of performance psychology derived from athletes apply to surgeons?  Are there unique aspects of consulting with this population?

This presentation addresses performance psychology applied in medical settings, with special emphasis on the role of the mental skills of surgeons.  After a review of the limited data available on how surgeons approach the mental aspects of performance, it will explore recent efforts to incorporate performance psychology into the training of physicians.  We will look at case examples of how the seven mental skills associated with peak performance of athletes (Williams & Krane, 1997) have been applied in working with physicians and surgeons.    The presentation concludes with specific recommendations for individuals considering consulting with this unique population.

Resources

The information presented today comes from various sources.  My colleague, Kate Hays, and I are in the process of writing a book on Performance Psychology.  As part of that project we have interviewed physicians, surgeons and individuals who consult in medical settings.  In addition to these formal interviews, I have drawn from my work with physicians and surgeons in private practice over the past twenty plus years.

Traditional Training

Historically, the training of surgeons can be described as “militaristic.” One needs to be tough and simply do the work.  If you are tough enough to perform the technical skills, you don’t need anything else.  One is expected to “stand alone” and take care of business without concern for the mental or emotional aspects of the process.  Katz (1999), a medical anthropologist, likens a surgeon in the hospital setting to a “heroic action figure” in a culture that discourages discussion or even acknowledging doubts or uncertainties.

Current Practices

From our interviews with surgeons, we have found that many develop coping techniques and skills similar to those used by elite athletes for peak performance. These skills and practices have frequently developed through serendipity or a trial and error basis.   For example, surgeons frequently mention a process that can be described as imagery or mental rehearsal during their scrub routine prior to an operation.  This is a time of rote physical preparation during which many individuals report mentally rehearsing the upcoming procedure, including contingency planning for difficulties.

It is increasingly common for Family Practice training programs to have a behavioral health component.  This component provides both fundamental training in behavioral health issues, and often serves as resources for residents and interns struggling with the stresses of medical training and practice.  These programs have traditionally been geared more towards remedial or problem issues.  The efforts are typically directed towards bringing performance up to a minimal competency, rather than enhancing performance that is already adequate.


A lot of times . . . I will look at the angiogram – the dye study that shows the aneurysm and the anatomy around it. And typically what we will do is position the patient, prep the wound, look at the angiogram films and kind of imprint them in your mind. And then just go out into the scrub sink where you are by yourself. You’ve got five minutes there. And all you’re doing is just scrubbing your hands and it’s just a time of rote activity. You are not really talking to anybody; you’re not doing anything different except just standing there. And that’s the time I’ll try to piece together the anatomy with what I am about to do. If I am trying to do anything, I try to picture what I am going to see when I get there, because the x-rays are taken at a couple of fixed angles straight on or from the side, and we are coming in at a 20-degree angle to that. We try to transpose those two views in two-dimention to make it three-dimentional and rotate into the view that you’ll be looking at when you come down. And that is helpful.
(Neurosurgeon)


Bright Spots

In spite of the seemingly non-hospitable cultural environment, there are some notable situations where the mental and emotional aspects of performance have and are being addressed.

The Congress of Neurological Surgeons recently named Dr. Gazi Yasargil the Neurosurgeon of the Century.  This eminent surgeon is noted for addressing the mental aspects of surgery beyond the technical.  He regularly compares effective surgery to performing a symphony, and refers to his six-person operating team as  “a sextet who must perform together like an orchestra” (Brandsgaard, 2000).  Throughout his years of training medical residents, Dr. Yasargil has encouraged the development of routines and skills that address the mental, emotional, and non-technical aspects of surgery.

Tribble and Newburg have been gaining recognition for integrating mental and emotional components into the residency program of the School of Medicine at the University of Virginia.  In addition to addressing the mental aspects of surgery, they strive to create a learning environment that emphasizes “personal engagement.”  This involves personal awareness, emphasis of process rather than outcome goals, and a conscious focus on activities that create energy for oneself.

Linnea Hauge has brought her sport psychology background to Rush Hospital in Chicago where she is an educational coordinator for the resident’s program.  Integration of sport psychology concepts is reflected throughout her programs and work.  Hauge notes some of the similarities between surgery and sport as a) exceptional skill sets are required; b) team leadership is necessary; c) a multitude of factors impact performance, in a given situation; and d) participants “dress out” to perform.

Sport Psychology Techniques in Surgery – Specific Examples

For individuals with a background in performance enhancement, there are numerous circumstances where the knowledge base of sport psychology is applicable to surgery. Here are some examples from my own practice where the seven key mental skills of athletic performance, as identified by Williams and Krane (1996) have been adapted to medical settings.

Key Mental Skill

Application in Surgical Setting

Goal Setting

Performance goals

  • Reducing medication
  • Effectively handling distracting thoughts

Process goals

  • Taking breaks throughout the procedure
  • Stepping back, stretching and breathing
  • Incorporating a pre-performance routine

Imagery

  • Hypnosis (focus on relaxation and cues for relaxation)
  • Mental rehearsal of procedures and coping with various scenarios

Thought Control Strategies

  • Identifying negative thoughts and developing appropriate counters
  • Focus on alternate cognitions and beliefs

Arousal Management Techniques

  • Centered breathing
  • Hypnosis

Well-Developed Performance Plans

  • Incorporating mental routines throughout the operating procedure
  • “Time out” break to stretch during the procedure
  • Resting/bracing hands whenever possible

Well-Developed Coping Strategies

Specific plans for potentially troubling situations

  • Fatigue
  • Fear
    • Physical abilities
    • Colleague’s evaluation

Pre-Performance Mental Readying Plans

  • Reviewing affirmations prior to “dressing out”
  • Mental rehearsal during scrub routine

Recommendations

Perhaps the greatest challenge in working with surgeons is the same challenge faced when consulting in other areas: simply gaining access. Individuals considering work in this setting should be aware that consultation is different from therapy. Rather than presenting an overview of basic consultation guidelines, I want to address aspects that appear particularly critical when consulting in a medical setting. My grandfather used to say, “it’s not what you know that is important; it is what people do with what you know.” The consultant is advised to keep two things in mind, if you want physicians to listen to what you have to say.

First, promote education rather than remediation.  The culture of surgery implicitly demands perfection.  Education of residents and continuing education for practicing surgeons is perfectly acceptable; acknowledging deficits is contrary to the culture and can potentially undermine the confidence that a surgeon needs to confront life and death situations a daily basis.   Even in circumstances that might be diagnosed as performance anxiety, I have found it more helpful to approach the situation from a performance enhancement rather than deficit model. In my experience, it is not uncommon for surgeons and physicians to use beta-blockers to treat symptoms of anxiety associated with performance.  Usually the symptoms are managed with mild medication and therefore technically not problematic. Nonetheless, individuals who perform adequately in such situations have requested to “enhance performance” by learning how to do so without the benefits of medication.

Second, present suggestions in a “cafeteria-like” fashion.  While this is a good guideline for effective consultation in general, it is particularly true in working with surgeons.   Simply put:  most people don?t like to be told what to do.  Extremely bright, talented, leaders who are accustomed to making life-and-death decisions on a daily basis really don?t like to be told what to do.   By bringing your knowledge to the table in a collaborative fashion, the surgeon can choose for him or herself what has the best chance of success.

Surprise Observation

On a final note, there is an additional factor that has seemed important when I have worked with physicians or surgeons on an individual basis.  I have found it extraordinarily helpful to discuss spirituality and the personal belief system of the individual.  In recent years, spirituality has received growing attention in the therapeutic process.  To my knowledge, there has been little attention to its role as a dynamic of performance enhancement.  I increasingly am finding that the techniques of performance enhancement are like bricks, and spirituality is like mortar.  One can lay bricks without mortar and make a “stack wall” which can be beneficial in many circumstances.  But if one incorporates those techniques within a belief system that includes a sense of purpose and meaning to life, those bricks create an incredibly strong foundation that can serve as a resource in facing the toughest of circumstances – circumstances such as facing life and death performance on a daily basis.

Brandsgaard, B. (2000, February 23).  U.S. Home to World’s Best Neurosurgeon. [On-line] News release from the University of Arkansas Medical Sciences.  Available: http://www.newswise.com/articles/2000/2/SURGERY.UAM.html

Katz, P. (1999). The scalpel’s edge:  The culture of surgeons. Boston:  Allyn and Bacon.

Williams, J. & Krane, V. (1997). Psychological characteristics of peak performance.  In J. Williams (Ed.), Applied sport psychology: Personal growth to peak performance.  Mountain View, CA: Mayfield Publishing Company.

*Originally part of the symposium, “Performance psychology innovations: Applications for dancers, musicians, surgeons and executives,” presented at the 2001 Convention of the American Psychological Association, San Francisco, CA  August 26, 2001.

#### Copyright 2001, Dr. Charlie Brown. All rights reserved.###