EMind Evidence 02
Exploring the links between expert performance in music and surgery: what surgeons (and the rest of us) can learn from how musicians train.
The Quick Look
"Enhancing surgical performance by adopting expert musicians' practice and performance strategies." Rui M, Lee JE, Vauthey JN, Conrad C. Surgery. 2018. PMID: 29336812.
Find it here.
Surgery and music are both performance arts requiring the ability to successfully and consistently execute sophisticated techniques with precision and grace despite stress, fatigue, and other forms of pressure. In this study from The University of Texas MD Anderson Cancer Center, the investigators dug into the scientific literature about what effects expert level musicians perform at their peak--and what prevents them from doing so--with the goal of exploring what surgeons might learn from their musical counterparts.
The authors identify five areas of potential similarity between surgical and musical performance that surgeons might exploit: (1) the role of deliberate practice in training, (2) the importance of ambidexterity, (3) the role of competition and self evaluation, (4) mitigating physical injury, and (5) performance anxiety. Of these, numbers 1, 3, and 5 are most directly applicable to performing during an emergency. From reviewing scientific literature in musical performance, the authors make the a number of suggestions for improving surgical performance, including that: surgeons should practice deliberately and consistently, and minimize complex surgery after days off; surgeons should study video, both of experts performing a particular procedure and of themselves operating in order to learn best practices and perform self-review. Finally, to minimize hand tremors, surgeons should be well fed and rested and minimally caffeinated before a complicated procedure. They might also consider low dose beta-blocking medication as a performance supplement.
Retrospective review of the existing scientific literature on expert performance in music and surgery from 1974-2017, selected using a PubMed search for 20 a priori identified terms. After reviewing 82 scientific studies, the authors used Nominal Group Technique (an iterative group brainstorming / voting technique) to identify five key areas of focus. Within each focus area, the authors identified key papers and made recommendations on how surgeons could improve their practice based on principles identified in the literature on musical performance.
- The five focus areas identified were (1) the role of deliberate practice in training, (2) the importance of ambidexterity, (3) the role of competition and self evaluation, (4) mitigating physical injury, and (5) performance anxiety. Essentially this was the real finding of the paper, and the rest of the findings listed below come from individual studies the authors reviewed (some of which we will explore in future EMind Evidence posts).
- Deliberate practice among surgical residents led to improved laparoscopic surgical performance compared to standard training techniques.
- Taking days off of operating may result in increased mortality in complex cases upon return to the OR, resulting in the suggestion that surgeons not schedule complex cases immediately after multiple days off.
- Watching videos of their own performance and watching pre-recorded videos of experts performing procedures both led to improvement in surgical skill.
- Hand tremor effects may effect surgeons regardless of their level of training, and may be minimized by addressing proper eating, sleeping, and caffeine intake.
- In some cases, low dose beta-blocker therapy (10-40mg propanolol around an hour before surgery in these studies) can improve performance anxiety, hand tremor, and surgical performance.
The link between how expert musicians and expert surgeons execute skilled movements under the pressure of performance is compelling, and this paper reviews several scientific studies in both fields that might benefit surgical performance. But how does this help us as we train to improve our performance during emergencies?
First, under the category of removing unnecessary opportunities for failure (see Episode 03 of the podcast, with Lieutenant Amy Hildreth, MD), the paper suggests several things we could do to proactively minimize potential mistakes during a critical case. Specifically, we could (whenever possible) improve our nutrition / sleep / caffeine balance and learn to optimize nutrition and caffeine over the course of our shifts. This is obviously not trivial, especially if you work shifts that alternate between day and night, or are unexpectedly thrust into an emergency, but it's worth working on for sure. Perhaps keeping a notebook of the quality of your decision making and mood, and the flexibility and speed of your thought processes as you experiment with different protocols in optimizing your physiology for performance. It is unlikely there is going to be a one-size fits all answer here, so experimenting with what works best for you is going to be key.
Second, the paper suggests that we can benefit greatly from both prospective and retrospective review of case videos. Prospective review of videos of experts performing rare or complex procedures can help us improve our readiness to perform under pressure - for example, see this video review of placing a transvenous pacer, or the deep jiu jitsu video library available at MMALeech, which is run by Coach Gustavo Gasparin from Episode 08. Retrospective review of our own cases could help us improve our technical skills and identify opportunities for improvement. Currently, none of the sites where I work perform in situ recording of actual emergency cases, but recording and reviewing simulated cases is likely to be high yield and worth pursuing.
From a scientific perspective, this is more of a guided tour of the performance literature than it is a systematic review. There is a lot of value in this approach, especially when the tour guides clearly are deeply knowledgable in the field as they are here, but the review method was limited by its reliance on searching a small number of a priori terms in a single database. It is possible that there are other studies that might provide more or contradicting evidence between the two disciplines. Additionally, it is not clear how the authors arrived at the five focus areas--a more formal Delphi process, as opposed to the Nominal Group Technique might have added rigor and breadth to the results.
- Dive deeper into the performance literature to explore the signals the authors review here (we'll do that in future EMind Evidence posts)
- Experiment with different combinations of nutrition / sleep / caffeine -- since you're probably already changing these things day to day anyway, the first step might be journaling about the quality of your decision making performance and noting trends for potential improvement.
- Consider video recording and retrospective review of your own performance on simulated cases. Whenever possible, seek out and study video of experts performing what you're trying to do.
- More ideas? Comment below, we'd love to hear them.