Finding the Elusive “Peak Performance” in Surgery: HSS Study

What is “peak performance” in orthopedic surgery? A team from Hospital for Special Surgery (HSS) in Manhattan decided to define and answer that question by way of a review of the literature regarding training principles which may (or may not) help trainees achieve peak performance.

Todd Albert, M.D., Surgeon-in-Chief Emeritus at HSS, explained the genesis of this novel study to OTW, “This work was prompted by Drs. Philip Louie and Michael McCarthy after discussions and a lecture on performance, leadership and burnout.”

Mind/Body in Orthopedic Training

Starting with a sports metaphor, the authors opened up their review by noting that “achieving peak performance in athletes highlights the intimate relationship between mental and physical capabilities. Surgical trainees face a similar environment where learning occurs in tandem with the performance of surgical techniques.”

“The concurrent development of mind and body highlights the complex interplay of training, highlighting the notion of deliberate practice. Deliberate practice is widely used by novice and professional athletes and musicians, as this exercise provides a structure for both self and outside critiques, which allows for further refinement.”

Mindfulness has been successfully used in athletics and performance arts, among other domains. The study authors recommend that through such mental training programs, surgical trainees can sharpen their self-awareness, mental toughness, emotional self-regulation, and surgical performance.

As for how programs might encourage trainees to engage in a mindfulness practice, Dr. Albert told OTW, “We should make it an important part of trainees’ time and the leadership of a particular program should recognize its importance and value.”

Goal Setting and Accountability

Consider what you most want to gain from your training, advise the authors, recommending the Specific, Measurable, Attainable, Realistic, and Timed (SMART) goal-setting technique.

“The inability to accomplish goals often occurs when the goals are neither achievable nor realistic,” say the researchers. “Once the goals are set, you need to constantly remind yourself of your goals. It may be helpful to write them down and place them where you can physically see them…When you hold yourself accountable to your goals, you are communicating to the universe (and to yourself) that the goal is a priority. This can take a combination of many forms as follows: telling a friend, joining an accountability group, hiring a coach, using technology (i.e., apps), or simply writing them down repeatedly.”

“The majority of trainees (if not all) set goals,” said Dr. Albert to OTW. “The variability comes in their dedication and organization in a defined plan for attainment of the goals.”

Simulation

Whether it’s a bioskills lab or virtual reality simulation, say the researchers, these efforts can result in enhanced surgical accuracy amongst trainees. “Trainees seeking efficient and effective training methods should critically assess areas of weakness and actively seek out opportunities addressing skill deficiencies…Mastering skill sets outside the OR affords residents to have capable and proficient hands promoting opportunities for expanded involvement in the OR.”

Perseverance and Grit

“In particular, grit describes the capacity to sustain both effort and interest in projects that take long durations to complete, as in surgical residency training…”

Citing a prospective, multi-institutional study on grit and attrition across 12 general surgery resident programs (“Grit: A marker of residents at risk for attrition?”), the authors point to results indicating that grit appears to be a “promising marker and risk factor for attrition from surgical residency.” The authors of the grit/attrition study recommend that programs “consider screening for grit in current residents and directing support to those residents with below-median values, with a focus on building family, friend, and formal mentor relationships.”

Growing Grit

First, say the authors, those who undertake the surgical training process will be best served by the belief that they can grow. “Unfortunately, when some face a setback, they give up because they think it is a sign that they never had ‘what it takes’ to succeed; thus, they have a ‘fixed mindset.’ By adopting a ‘growth mindset’ with hope, you can change your approach to build your grit. Thus, you can learn to stick with something, even when the going is not easy, especially over a period of residency training.”

Second, they say, accept frustrations and failure as part of the process. Asked how a mentor could help a trainee accept failure, Dr. Albert commented to OTW, “Be there for them. Help them realize that it is a part of life and to use it and turn it into a potential positive/opportunity for the future.”

Third, the authors note the value of “focused productivity.” To this end, Dr. Albert and his co-authors recommend the Pomodoro Technique, a time management system whereby you break the activity into 25-minute work periods separated by 5-minute breaks. “The constant timing of your activities makes you more accountable for your tasks and minimizes the time you spend procrastinating….”

Mentoring

Noting that “Residencies with formal mentoring programs have shown substantial effects on personal development, career guidance, career choice, and research productivity,” the study authors say, “The mentor-mentee relationship builds a stronger sense of community among colleagues, providing professional fulfillment and job satisfaction outside our regular tasks as surgeons.”

Definitely a win-win for surgeons…and ultimately, their patients.