The Psychology of Surgery

LET’S BE CLEAR, there is no plush couch sitting in the corner of Nicholas Anton’s office. No serene paintings. No inspirational quotes. No framed degrees adorn his walls. No bookshelf in the corner stuffed with Freudian tomes. Anton is a mental performance coach but the people who come to him—in the basement of the Rotary Building on the campus of Indiana University School of Medicine—aren’t here to bare their souls. They almost never shed tears. When there is introspection, it is to serve one purpose: To make surgeons perform better in the operating room.

“I’m focused on performance,” Anton said. “I’m not saying, ‘Tell me how you feel.’ We want concrete and objective outcomes.”

Anton helps surgeons climb over barriers that compromise their performance. He helps them optimize the way they think about their work and how they control their fine motor skills when it matters most—with a patient under the operating room lights.

Surgeons, it turns out, must not only confront complex technical challenges but also possess a keen understanding of the roles and pressures faced by the other people huddled around the patient—the anesthesiologist, the technicians and the nurses.

Anton, whose training is in sports psychology, came to the School of Medicine three years ago. He followed Dimitrios Stefanidis, MD, PhD, from Carolinas Medical Center. There, Anton and Stefanidis devised and deployed a mental skills curriculum for surgical trainees. They brought it with them to IU, where Anton encounters physicians in the earliest stages of their training and tailors the curriculum to their needs. Anton also stands by their side as they put it to use during exercises in IU’s Surgical Skills Center.

For Anton, the goal is to steel the surgeons for the anxiety and stress that becomes visceral once they pick up a scalpel or manipulate a laparoscope.

Gary Dunnington, MD, who chairs the Department of Surgery, views mental skills coaching as a logical step in preparing residents for life in the operating room.

IT’S PART OF a plan Gary Dunnington, MD, the Jay L. Grosfeld Chair in Surgery, has been putting into place to upgrade the department and enhance its culture since arriving in 2012.

Now, surgeons are no longer trained in an operating room based on whatever patient rolls in that day. Today, IU’s residents spend five years steadily progressing through modules taught by faculty who perform the operation each day. It enables them to isolate the components of a case, talk about the risks and do some troubleshooting. All along the way, Anton is there to coach them in mental strategies.

“It didn’t take long for our residents to realize what an asset it is to have a psychologist when they’re struggling,” said Dunnington, a national leader in surgical education.

Among those who see the need is fourth-year surgical resident John Martin.

“You’re drinking from a tsunami wave,” Martin said. “If you don’t have skills in place to pluck information, organize it and develop a cognitive schema about patient care, you drown.”
Anton’s job is to help them stay afloat, and learn to ride out the storms.

“By applying mental skills throughout the process, they’re developing those habits,” Anton said. “They reinforce themselves as they take on more complex procedures.”

There’s a certain baseline level use of these skills already. We just want to provide these tools to add to their tool belt and structured practice using them earlier on in their careers.

Starting in the latter half of their first year, residents meet with Anton every two weeks for a 90-minute session. Usually, the resident spends 45 minutes watching a video about a skill, completing workbook exercises and talking about how they have used the skill before. Next, they move to the Van Nuys Medical Science Building to practice in the Surgical Skills Center.

Like the mental coaching, the facility itself has come a long way in recent years.

When IU was trying to woo Dunnington from Southern Illinois in 2012, it put off showing him the old surgical skills center, which was a live-animal facility in a cramped basement and a few virtual reality simulators. “It just wouldn’t do,” he recalled.

Now IU utilizes a gleaming new 2,200-square-foot facility. Aside from cadaver work, it features laparoscopic, vascular and endoscopic simulators so realistic that “blood” splurts from arteries and surgeons are confronted with “patients” who will “die” without intervention.

When you strip away a surgical residency to its essence, the job is teaching doctors how to use their hands. A laparoscopic procedure, such as removing part of a colon, boils down to fine motor skills. Claspers are extensions of fingers. They create tension, clip tissue, guide needles and tie knots.

“It’s like learning to tie your shoelaces all over again,” Martin said. “It’s wild watching competent adults struggle to tie a knot.”

Anton finds that residents are often unaware of the stressors that can impact their performance—anxiety that comes from their station in life. They may be struggling with time management, unable to squeeze in enough practice in the skills center or working next to a faculty member whom they’ve butted heads with in the past. Their greatest fear is the threat of having a case pulled.

“If they make a mistake, in addition to concern for the patient, there’s a worry the attending will step in and not let them complete it,” Anton said. “A lot of it becomes compartmentalizing those fears and focusing their attention on their action plan for the case.”

Anton teaches them breathing techniques to achieve calm and how to reframe negative thoughts before they become a distraction. He shows them how to use mental imagery to anticipate potential trouble spots.

“There’s a certain baseline level use of these skills already,” Anton said. “We just want to provide these tools to add to their tool belt and structured practice using them earlier on in their careers.”

“The data are overwhelming that residents who train in a surgical skills center do procedures faster and with fewer errors.”

ASIDE FROM TEACHING residents, Anton works with Stefanidis to assess their effectiveness. The pair have a paper under review reporting that residents who underwent their training performed significantly better—a result they hope to use as a launch point to train surgical teams.

“Among this generation of surgeons, there’s a recognition that they need to be receptive about how the whole team is performing,” Anton said. “Emotional intelligence is critical.”

Meanwhile, Nicole Kissane Lee, MD, who is director of the Surgical Skills Center, vets each module, scrutinizing its content, materials, and assessment process to make sure it complies with national guidelines. “It’s not just playtime,” said Lee, who completed a fellowship in medical simulation and earned a master’s in education from Harvard University.

Few residency programs are as rigorous in their assessment of the trainees, Dunnington said. Before a surgeon-in-training carries out a new procedure on a patient, he or she is videotaped doing it in the skills lab. Next, the footage is exported to a faculty member’s desktop computer for close scrutiny.

“For us, it’s a patient safety issue,” Dunnington said. “The data is overwhelming that residents who train in a surgical skills center do procedures faster and with fewer errors. If I’m a patient, I prefer that.”

For Martin, the surgical resident, it is a learning environment ideally suited to the rigorous career in front of him.

“These are not soft skills,” Martin said. “They have a real impact on how you process information and confront difficulties during your day. You make decisions fast, and you have to live with the consequences if they don’t pan out.”

To support surgical training at Indiana University School of Medicine, contact Lee Vriesman Abrams at lvriesma@iu.edu or 317.278.3602.