Measure twice and cut once is a well-known phrase among surgeons, but this is not
always what happens. To better prepare new surgeons for the operating room, University
of Houston (UH) computer scientists are working with medical researchers at the Methodist
Institute for Technology, Innovation and Education (MITIE) to improve existing training
processes. At the core of their effort is understanding the role of stress on a surgeon’s
path to competency. Ioannis Pavlidis, director of the Computational Physiology Laboratory at UH, Dr. Barbara
Bass, chair of the department of surgery at The Methodist Hospital, and their colleagues
describe their findings in a paper titled “Fast by Nature – How Stress Patterns Define
Human Experience and Performance in Dexterous Tasks.” The article appears in Scientific Reports, the new open-access research publication from the Nature Publishing Group.
The group recently completed a three-year study funded by the National Science Foundation
(NSF) that measured the stress levels of physicians during surgical training. In addition
to the $500,000 from NSF, the researchers received a $200,000 grant from the John
F. and Carolyn Bookout Fund to supplement the study.
Pavlidis and his colleagues developed a non-contact method of measuring stress and
the body’s response to threats or challenges. This new thermal imaging method is capable
of quantifying performance and physiological stress indicators by measuring facial
perspiration, revealing how a person reacts to a threatening situation. This is called
a sympathetic response. Pavlidis, Bass and their teams were able to monitor these
sympathetic responses of 17 surgeons – 10 experienced and 7 novices – while engaged
in laparoscopic surgical training over the course of several months.
Bass, an authority in surgical education and director of MITIE, had long recognized
that surgeons in training exhibit stress as they learn to perform surgical procedures.
The team hypothesized this stress could be measured using the thermal facial mapping
technology developed by the Pavlidis research laboratory and set out to determine
if facial thermal stress would correlate with surgical skill performance.
“We found that regardless of experience level, surgeons attempt to perform tasks at
the same speed,” Pavlidis said. “This is counterintuitive, because you would expect
common sense to tell a novice to be more careful and slow down in an effort to reduce
errors. This was not the case in our study. Instead, the novices attempted the tool
transferring, cutting and suturing tasks as fast as the experienced surgeons, thereby
making many more errors due to their lack of experience to accommodate such speed.”
This led Pavlidis and his colleagues to question why this was the case, and they discovered
that high stress levels in novices were the likely trigger of fast behavior. When
presented with a challenging task, he said, the basic human instinct of survival mode
kicked in precipitating action, even if the speed of that action was counterproductive
for the desired result.
“While we hypothesized that stress is a factor in surgical training, we were not aware
of the impact of stress on the learning process,” Bass said. “This behavioral pattern
and its cause were well hidden, because until recently, objective stress measurements
in natural settings were difficult. Even if such measurements were feasible, educators
would not likely have made the connection since current metrics for skill acquisition
are often based on the time required to execute a task. The results of this study
suggest that we rethink our philosophy of training to an endpoint that includes speed,
as opposed to stressing precision in skill development, even if the pace of skill
execution is deliberately slowed.”
With this knowledge, Bass, Pavlidis and their colleagues strive to change the current
standards of surgical training that grade only on time and error performance without
taking “nerves” into account. Incorporating the testing of physiological reactions
into the process would reveal whether surgeons have truly stopped internalizing the
fear despite the dexterity they are able to exhibit externally in current training
evaluation methods.
“Our goal is for surgical training to go beyond just measuring time and errors at
face value,” Pavlidis said. “Instead, we also must look at the sympathetic responses
that are the telltale sign of whether a surgeon is in control of his or her anxiety
with the task at hand and ready to move beyond simulated surgeries and be trusted
with human patients.”
The key, the researchers believe, is to reduce stress levels in the initial stages
of training. Reduction of stress may result in reduction of attempt pace and consequent
reduction of errors.
“Surgeons have long considered speed to be a metric for efficiency in surgery,” Bass
said. “However, this study demonstrates that speed during skill acquisition is, in
fact, a counterproductive metric and one that may need to be specifically interrupted
to enhance training efficiency.”
It is likely a broad problem, Pavlidis says, with stress appearing to interfere with
the skill acquisition process in general. Therefore, a future area he’d like to pursue
is finding a way to reduce stress that would allow novices across a variety of professions
to attempt tasks at speeds more commensurate with their experience. He says if trainees
could just slow down, then it may shorten the training time and enhance their experience.
Lasting more than three years, this multidisciplinary effort included surgeons, computer
scientists, engineers and statisticians. In addition to Pavlidis and Bass, key contributors
included Panagiotis Tsiamyrtzis from the department of statistics at Athens University
of Economics and Business; Dvijesh Shastri, Avinash Wesley, Yan Zhou, Peggy Lindner,
Pradeep Buddharaju and Anitha Mandapati from UH; and Drs. Rohan Joseph and Brian Dunkin
from MITIE.
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Editorial Note: High-resolution photos of the team are available to media by contacting
Lisa Merkl. Video is available at http://youtu.be/LgnDyBQIfMQ.
About the University of Houston
The University of Houston is a Carnegie-designated Tier One public research university
recognized by The Princeton Review as one of the nation’s best colleges for undergraduate
education. UH serves the globally competitive Houston and Gulf Coast Region by providing
world-class faculty, experiential learning and strategic industry partnerships. Located
in the nation’s fourth-largest city, UH serves more than 38,500 students in the most
ethnically and culturally diverse region in the country. For more information about
UH, visit http://www.uh.edu/news-events/.
About The Methodist Institute for Technology, Innovation and Education
The Methodist Institute for Technology, Innovation and Education is a state-of-the-art
surgical education and training center focused on continuing education and training
of health care providers in practice. MITIE conducts groundbreaking translational
and clinical research on the development and testing of new procedures and surgical
technologies, as well as on methods to improve education and training for health care
providers in these technologies. For more information, visit http://www.mitietexas.com/.