Passion, focus, discipline, presence of mind, positive attitude, emotional maturity, willingness to improve, maneuverability, common sense, dexterity, handling pressure are characters one would frequently associate with a sportsperson. Now add to this a good serving of surgical skill and knowledge, awareness of how the mind functions and a drive to save innocent lives and voila! you have the recipe for an ideal surgeon who is idolized by many.
Mental Practice is the conscious action of systematically and repeatedly imagining objects and movements without physically seeing or performing them with the intention of improving performance. It has been defined as ‘The repetition or rehearsing of imagined motor acts with the intention of improving their physical execution’ (A). The concept has been successfully applied in professional sports for skills acquisition and performance enhancement. Its the repetitive process during training where an athlete is made to picture a contest in mind which he is most likely to face during the contest. An athlete before a game has to mentally prepare by introspecting his strengths, weaknesses and game plan, analyzing the strength of his opponent and how he has fared in the previous encounters. Now, isn’t this in many ways similar to how a Surgeon has to anticipate and get prepared for what he is operating on, plan to get it done smoothly while keeping his insecurities and pressures at bay? While the workspace of an athlete and a surgeon where they hone their skills are quite different and the fact that one of them is dealing with a life, aren’t all other factors, be it preparation or execution of plans essentially the same?
Motor imagery (MI) is a dynamic mental state during which the representation of a given motor movement is rehearsed in working memory without overt motor output. When athletes visualize or imagine a successful competition, they stimulate the same brain regions as one does when one physically performs that action. Visualization in sports or mental imagery is a way of conditioning for your brain for successful outcomes. The more one mentally rehearses his performance, the more it becomes habituated in one’s mind and athletes who use visualization eliminate some of the unknowns that create competitive anxiety. One study demonstrated that mental practice was associated with performance of a new motor task with lesser anxiety levels and better results (C). When athletes use visualization, they not only see the action unfold but truly feel the event take place in their mind’s eye. Bob Bowman, coach of the greatest Olympian, Michael Phelps included mental imagery as a part of Phelps’ mental training ever since he was a teenager, thanks to which he has more medals than a few nations put together. Each night before falling asleep and each morning after waking up, Phelps would imagine himself jumping off the blocks and, in slow motion, swimming flawlessly, the water dripping off his lips as his mouth cleared the surface and also what it would feel like to rip his cap off at the end. He would do this with his eyes shut again and again, until he knew each second by heart.
The motto is to visualize. Mental practice enhances even surgical technical skills and perfromance and maybe used as a time- and cost-effective strategy to augment traditional training in the operating room. As a Surgeon, visualize in more than three dimensions, starting with positioning of the dog, draping, incising the skin, separating the fat, seeing what muscles are underneath, knowing what instrument you would use to hold them or cut them with. Experience the feel of every structure, gentle handling of those tissues, even the possible splash of blood if you can! Then ponder over how you deal with the actual pathology in place, what you would or should do to correct it and what suturing technique would be best to close the wound and so on. The idea is to watch it all yourself perform before you actually do it; in your head.
Several studies have considered how mental practice might be applied to surgical skills acquisition and improvement and have recognized the benefits of mental practice in laparoscopic surgery (E), gynecology(F), and urology (G).
DesCôteaux and Leclère reviewed available literature and concluded that learning surgical skills is a highly intellectual activity and requires processing of perceptual information received from proprioceptive, visual, olfactory, auditory, and tactile sources (H). Furthermore, knowing how to perform an operation requires more than simply knowing the steps involved. For example, the perceptual information gained from previous performances is of paramount importance when planning and executing motor movements (e.g. Knowing how much one can ‘exteriorize’ the ovarian pedicle safely, how to move your wrist and hand to rotate a suture when closing an incision and so on).
Sanders et al. studied basic suturing skills in 65 medical students randomized to physical practice alone or a combination of physical and mental practice. The three randomized groups received either: (1) 3 sessions of physical practice on suturing a pig’s foot; (2) 2 sessions of physical practice and 1 session of mental imagery rehearsal; or (3) 1 session of physical practice and 2 sessions of imagery rehearsal. All participants then had to perform a specific surgery on a live rabbit. Performance was evaluated by a physician/teacher using a certain pre-determined rating scale and they found not only that mental practice was as effective as physical practice, but it was also more cost-effective, and that physical practice followed by mental imagery rehearsal was statistically equal to additional physical practice (I).
One study observed that the quality of mental imagery improved with more mental practice and that participants became better at this skill with repeated sessions and were able to further augment their performance (J). Another study(K) in Italy assessed videogaming enhancement (using the motion gaming console- Nintendo® Wii™ of spatial attention and eye-hand coordination in surgical residents and concluded that the Nintendo® Wii™ might be a helpful, inexpensive and entertaining part of the training of young laparoscopists, in addition to a standard surgical education based on simulators and the operating room.
McDonald and Orlick investigated the mental strategies related to performance excellence in surgery by interviewing board certified surgeons. The study(L) reported that surgeons consider mental readiness the most important type of preparation, followed by technical and physical readiness (49%, 41%, and 10%, respectively). Mental readiness often referred to positive thinking (97%) and positive imagery (79%), i.e., envisioning good outcomes with minimal complications.
It has also been suggested that mental practice might be an effective stress-management tool for practicing surgeons. In a qualitative study on stress in the surgical suite, surgeons described mental rehearsal and preoperative planning more broadly as effective coping strategies. Mental rehearsal and relaxation training were associated with higher number of coping strategies, increased nontechnical skills scores, and lower stress levels among surgeons(M).
When Desire and imagination compete against each other in the subconscious mind, its imagination that trumps desire. You wanting to perform a relatively challenging procedure will in all certainty leave you disappointed if end you up imagining the worse outcomes because your intuitive unknowingly works towards accomplishing your imagination more than your desire.
In conclusion, although mental imaging cannot and should not replace physical practice of surgical skills, sport psychology literature shows us that it can augment and improve them. Beyond the acquisition of surgical motor skills and their refinement, mental practice also provides room for holistic personality development. So, try sweating it out on the field and come up with a ‘Game plan’ before you step into the OR next time round.
Further reading
1) Malouin F, Richards CL. Mental practice for relearning locomotor skills. Phys Ther. 2010 Feb;90(2):240-51. doi: 10.2522/ptj.20090029. Epub 2009 Dec 18. PMID: 20022993.
2) Halvari H. Effects of mental practice on performance are moderated by cognitive anxiety as measured by the Sport Competition Anxiety Test. Percept Mot Skills. 1996 Dec;83(3 Pt 2):1375-83. doi: 10.2466/pms.1996.83.3f.1375. PMID: 9017755.
3) Arora S, Aggarwal R, Sevdalis N, et al. Development and validation of mental practice as a training strategy for laparoscopic surgery. Surg Endosc. 2009;24(1):179-187
4) Rogers RG. Mental practice and acquisition of motor skills: examples from sports training and surgical education. Obstet Gynecol Clin North Am. 2006;33(2):297-30
5) Komesu YY, Urwitz-Lane RR, Ozel BB, et al. Does mental imagery prior to cystoscopy make a difference? A randomized controlled trial. Am J Obstet Gynecol. 2009;201(2):218e1-218e9.
6) DesCoteaux JG, Leclere H. Learning surgical technical skills. Can J Surg. 1995;38(1):33-38.
7) Sanders CW, Sadoski M, Bramson R, Wiprud R, Van Walsum K. Comparing the effects of physical practice and mental imagery rehearsal on learning basic surgical skills by medical students. Am J Obstet Gynecol. 2004;191(5):1811-1814.
8) Immenroth MM, Bürger TT, Brenner JJ, Nagelschmidt MM, Eberspächer HH, Troidl HH. Mental training in surgical education: a randomized controlled trial. Ann Surg. 2007;245(3):385-391. http://refhub.elsevier.com/S1931-7204(13)00188-8/sbref8
9) Giannotti D, Patrizi G, Di Rocco G, et al. Play to become a surgeon: impact of Nintendo Wii training on laparoscopic skills. PLoS One. 2013;8(2):e57372. doi: https://dx.doi.org/10.1371%2Fjournal.pone.0057372
10) McDonald J, Orlick T. Excellence in surgery: psychological considerations. Contemp Thought Perform Enhancement. 1994;3-13-32
11) Arora S, Sevdalis N, Nestel D, Tierney T, Woloshynowych M, Kneebone R. Managing intraoperative stress: what do surgeons want from a crisis training program? Am J Surg. 2009;197(4):537-543.
Comments
Post a Comment