Mental 3D Visualization: Building Surgical Resilience for Performing High-Risk Procedures

Abstract

OBJECTIVE:

Psychological resilience has been studied in several demanding professions, including the military and competitive sports, yet specific strategies for managing stress are not commonly addressed during surgical training. The objective of this study was to investigate how surgeons view performance under pressure during high-risk surgical steps.

DESIGN:

Using constructivist grounded theory, we conducted 12 individual semi-structured interviews with a theoretical sample teaching surgeons, representing 10 different specialties and a range of experience. We drew on Luthar’s concept of resilience as positive adaptation, an active and flexible process in which critical choices are made in stressful situations. We asked about both protective and vulnerability factors contributing to resilience in high-risk surgery. We coded transcripts, transforming each category of codes into a visual schematic highlighting our findings related to performance under pressure and resilience, which we transformed into a conceptual model.

SETTING:

Truman Medical Center, Kansas City, MO, tertiary hospital.

PARTICIPANTS:

Twelve teaching surgeons from 10 different surgical specialties.

RESULTS:

Mental 3D visualization is necessary for proper preoperative planning, enacting contingency plans in the face of intra-operative challenges, and managing emotions during high-risk surgery. Each of these factors informs staying calm under pressure and is necessary for building long-term surgical resilience. Negotiating challenges in high-risk surgery is contingent upon adapting to risk developed over time through surgical experience, mental 3D visualization, intentionality, and self-reflection.

CONCLUSIONS:

Mental 3D visualization informs processes for staying calm under pressure and is essential for building long-term surgical resilience. We recommend that residency curricula offer progressive education on mental 3D visualization and foster intraoperative environments that promote adapting to risk.

COMPETENCY:

Practice-Based Learning and Improvement

INTRODUCTION

Acute intraoperative surgeon stress is a significant contributor to errors and poor technical performance.¹ Over time, accumulated distress over substandard surgical execution and repeated medical errors can lead to surgeon burnout.^2,3 Yet little is known about how surgeons develop discreet skills to adapt to surgical stressors inherent to challenging surgeries or how adapting to stress contributes to personal resilience. Performing high-risk surgery demands coping mechanisms similar to high-level athletics and professional music accomplishment,^4,5 including psychological and physical performance that mitigates emotional stress. Yet specific intraoperative strategies for managing stress are not addressed during surgical training.⁶

BACKGROUND

Psychological resilience has been studied in several demanding professions, including the military,^7,8 competitive sports,^4,9,10 and healthcare.¹¹ These studies suggest that those with a high level of resilience can maintain their performance by engaging in their problems in an active way. Staying task-oriented helps to maintain one’s focus on a problem, while minimizing distractions from unhelpful emotions.⁴ Learning to recover from stressful situations and grow from exposure to adversity is vital to professional development.¹² We are not aware of psychological resilience being studied in surgeons.

CONCEPTUAL FOUNDATION

We focused our examination of how surgeons adapt to stressful surgery and build long-term resilience using Luthar et al.’s concept of resilience as positive adaptation, in which resilience is viewed as a dynamic process occurring within the interplay of adversity and adaption.¹³ According to Luthar, resilience can follow stressful situations if the stress is linked to emotional intelligence, grounded in self-awareness, and informs adaptation. Adaption to stress involves making a choice of how best to react versus reacting impulsively.^12–14 Resilience in this sense can be viewed as competence centered around individual protective and vulnerability factors during high risk, stressful situations. Understanding how these factors contribute to overall performance in high-risk surgery and surgeons’ abilities to negotiate diverse stressors during complex procedures is important. Considered from this position, resilience is best understood from a developmental and social perspective – the specific conditions that promote vulnerability or protection from adverse life circumstances.¹³

The vulnerability factors of high-risk surgery are multifaceted, from managing the complexities of the surgical procedure to emotional concerns of performance errors and potential litigation. Yet surgeons are not always the best judges of personal stressors, and this can result in poor choices for adapting to challenges and in developing useful coping strategies.¹⁵ Awareness of individual vulnerabilities and development of protective factors through adaptive flexibility¹⁶ are essential.

STUDY OBJECTIVE

The objective of this study was to use Constructivist Grounded Theory to investigate surgeons’ perception of how they perform under pressure during high-risk surgical steps. If we can better understand the factors that influence a surgeon’s ability to maintain calm and focus^17–20 while executing high risk surgery, then stress management training for surgeons can be improved.

MATERIAL AND METHODS

We performed a qualitative study using Constructivist Grounded Theory (CGT)²¹ because of its strengths in generating knowledge through a systematic critical inquiry and allowing for an evolution of the researchers’ critical stance. We chose this approach, as opposed to deferring to a scale, to allow our participants to provide their own definitions of resilience specific to surgery, based on their lived experiences of conducting high risk surgical procedures. Following the principles of CGT, we started with a conceptual foundation concerning surgical resilience, built our semi-structured interview, strategized about participant sampling, and iteratively collected and analyzed data using constant comparison methods. We maintained a methodological self-consciousness by choosing a research method that reaffirmed our study objective and allowed the emerging data to generate critical questions that would challenge our perspectives. This led to reassessments, altering our research questions, and revising the interview to ask more progressively focused questions to reflect changes in our conceptualizations.²² Using memos and white board schematics, we developed visual maps to generate novel ways of viewing our data that considered all possible theoretical explanations. Our findings were used to build our conceptual model of resilience-building in high-risk surgery.

Research Team

Our research team consisted of a medical student researcher (FM), a humanities-trained researcher (MB), and a surgeon specializing in female pelvic reconstructive surgery (GS). Each member of the team participated in the initial literature review, study conceptualization, and data analysis. Data collection was performed by FM and MB. The model was developed by FM and modified by the other members of the research team. FM, MB, and GS drafted the manuscript.

Setting and Participants

The research took place in a Midwestern United States multi-specialty hospital. The hospital contains many surgical residency and fellowship programs. We employed a theoretical sampling as described below. Each of our 12 participants were involved with supervising and teaching residents and fellows from those programs and represented 10 different surgical specialties including orthopedics, plastics, general surgery, and OB/GYN. Additional details about participants can be found in Table 1.

TABLE 1.

Demographics of Particpants

Subject	Specialty	Gender	Years of Experience	Training
SI	OMFS	M	>20	International
S2	OB/GYN	F	<5	US
S3	General Surgery	M	>20	US
S4	FPMRS	M	>20	US
S5	Pediatric - Spinal	M	>20	US
S6	Pediatric - Cardiothoracic	M	>20	US
S7	Neurosurgery	M	>20	US
S8	Plastics	F	>20	US
S9	Orthopedics	M	>20	International
S10	GYN Oncologist	F	<5	US
S11	Pediatric - Orthopedic	M	>20	US
S12	Pediatric - Cardiothoracic	M	<5	US

Note: our sample included 10 White participants and 2 Asian participants.

OMFS, Oral and Maxillofacial Surgery; OB/GYN, Obstetrics and Gynecology; FPMRS, Female Pelvic Medicine and Reconstructive Surgery.

Conceptual Foundation and Development of Semi-Structured Interview

We began with the question “How do surgeons cope with the pressure of performing high-risk steps?” Our question evolved as we discussed sequential literature reviews. We started with a review of performance under pressure in the military,^7,8 competitive sports,^{4, 9,10} and healthcare¹¹ and subsequently considered our conceptual foundation, drawing on Luthar et al.’s work on resilience as positive adaptation to stressful situations¹³ to build our initial semi-structured interview. We maintained a balance between reliance on this conceptual foundation and the emergence of new data.²³ We considered the concepts of performing under pressure, coping with stress, and visualization techniques.^9,24,25 The latter led us to explore mental 3D visualization^26–28 as a potential protective factor. We continually modified the semi-structured interview as we encountered these sensitizing concepts and new data. See Supplemental Material 1: Semi-Structured Interview Guide.

Data Collection and Analysis

We conducted 12 individual, semi-structured interviews. We employed theoretical sampling,²⁹ enrolling participants concurrently with data collection and analysis. We began with a convenience sample and sought new participants that would challenge our emerging concepts. For example, later in recruitment we sought participants with less surgical experience to challenge our initial findings of strategies that took many years to develop. In the interviews, we asked the participants to choose a high-risk surgical step, which we defined as either most highly associated with patient outcome or at greatest risk for patient injury. Interviews were conducted through Zoom due to the viral pandemic, lasted approximately 1 hour, and were audio and video recorded for transcription purposes. Our research team reviewed the transcripts, conducted coding and memo-writing, and used methods of constant comparison to identify major categories of codes. FM converted the data from each transcript and the findings from our group meetings to draw participant-specific visual maps. This was accomplished without a software package. These visual maps guided an iterative process of challenging our evolving findings and making changes to the semi-structured interview. Subsequent interviews led to the creation of more visual maps, which were used to build our conceptual model. See Supplemental Materials 2 and 3: Visual Maps.

Data Saturation and Member Checking

We concluded that we had reached data saturation using two methods concurrently: first, we used a constructivism approach looking for richness of data and diversity of perspectives aiming for conceptual depth.²¹ Our data collection was complete after we had compiled “rich and thick” data, meaning that the data was multilayered and detailed as well as plentiful enough to generate a core of understanding. This allowed us to elicit a complex narrative response from open ended questions. Secondly, we used the Guest et al. assessment of thematic saturation in qualitative research, which demonstrated that the bulk of our categories of codes were identified in the first six participants.³⁰ After construction of the conceptual model, we performed member checking by sending the conceptual model and a summary of our results to all participants, allowing for comment on data interpretation. We received affirmation of our model from six of the participants who responded.

Reflexivity

Each member of the research team engaged in a written reflective exercise to identify potential biases prior to developing our semi-structured interview. Consistent with CGT, we practiced Critical Inquiries, challenging our value positions with the data we exposed.²¹ Two participants were members of GS’s clinical Department, but GS did not participate in those interviews and all transcripts were de-identified. Each participant provided consent for participation. The study was reviewed and approved as exempt by the University of Missouri Kansas City Institutional Review Board.

RESULTS

We found that mental 3D visualization is necessary for proper preoperative planning, enacting contingency plans in the face of intra-operative challenges, and for managing emotions during high-risk surgery. Each of these factors informs staying calm under pressure and is necessary for building long-term surgical resilience. Both mental 3D visualization and adaptability to risk develop over time through surgical experience, intentionality, and self-reflection.

Our conceptual model of mental 3D visualization and surgical resilience is in Figure. Table 2 lists definitions, from our findings, of terms used in the model. The model illustrates two acts of mental preparedness that inform developing surgical resilience: mental 3D visualization and adaptability to risk. At the center of the model are intentionality and self-reflection, processes that ground cognitive preparedness and are necessary for weathering adversity. Arching out from this central concept, is mental 3D visualization on the left side of the model and adaptability to risk on the right, to illustrate their relationship to being intentional in one’s action as well as self-reflective for finding answers and working through complex problems. On the mental 3D visualization side on the left, a series of steps build toward surgical preparedness, from pre-operative planning to full development of mental 3D visualization of contingencies. These steps also contain key components important to expertise and proficiency: knowledge of anatomy and repetition over time. On the right-hand side of the model, adaptability to risk is developed during medical training and after, toward full preparedness for performing high risk surgery and becoming a resilient surgeon. Depicted here are the emotional skills of adaptation, from taking responsibility to developing humility. As with the mental 3D visualization side of the model, key components include emotional management over time, trusting in one’s plan of action, and access to mentor role models. As a whole, each side of the model informs the other, thus becoming a cyclical process of learning and doing. Below we present detailed Results corresponding to each portion of the model.

FIGURE 1.

Conceptual model of surgical resilience, informed by mental 3D visualization, adapting to risk, and intentionality & self-reflection.

TABLE 2.

Themes and Definitions Assembled From Our Data

Mental 3D visualization	The ability to understand, manipulate, and navigate through a mental 3D understanding of anatomical space
Knowing the anatomy	Familiarity with normal and abnormal anatomy
Contingency plans	A mental tool utilized to create a detailed plan for potential surgical scenarios
Flexibility	The ability to make changes to the established plan
Adapting to Risk	An internal state of calm that allows for managing adversity in situations prone to complications that protects from surgical burnout
Mentorship	Direct communication and observed behavior that influenced a trainee’s perceptions
Responsibility	Personal accountability that factors in the patient, the team, and the legal components
Trusting your plan	A confidence in surgical ability rooted in experience and depth of contingency plans
Emotional management	Ability manage emotional components of complications and successfully recenter and redirect
Humility	An understanding that surgery is inherently risky and that surgeons are humans who will make mistakes
Intentionality	Purposeful awareness of what one is doing
Self-reflection	An actionable exercise of introspection to assess thoughts, behaviors, and intrinsic nature

Mental 3D Visualization

Mental 3D visualization in our study is the ability to understand, manipulate, and navigate through a mental 3D understanding of anatomical space. Several participants described it as similar to imagining a map of the anatomy, one that aids them in mentally performing a surgery before operating on a patient. Our participants described an ideal 3D map as one that allows them to mentally reconstruct every step, including using the necessary instruments. Mental 3D visualization is developed actively during residency and is strengthened through simulation training and cadaver exposure. One participant noted “(you) have to work at it,” (S5) and another said “ [it] 100% improves your ability to perform the surgery.” (S2)

Knowing the Anatomy

Mental 3D visualization requires strong foundations in anatomy. Our participants viewed their mental 3D visualizations through the perspective of how they view anatomy in the surgery. In describing a mental 3D visualization, one surgeon assigned it a visual image, “In my head I’m picturing exactly how I see this defect and what I will be encountering in the OR.” (S12)

Repetition

Functioning like a map, the mental 3D visualization established landmarks for reorientation: “It is easy to get lost, [you need to] keep finding the familiar,” (S11) and was repeatedly described as easily mentally rotated in three dimensions.

Repeating surgical actions in a systematic manner was noted to influence the development and maintenance of the mental 3D visualization, and several of our participants linked their mental 3D visualization to the development of muscle memory, stating that executing the plan “through experience and preparation [until] actions become fluid,” (S6) until they “don’t think, just do.” (S9)

Contingency Plans

Many of our surgeons described using their mental 3D visualizations as contingency plans to prepare for various surgical eventualities: “The more you anticipate the better you are going to perform under pressure.” (S12). Other surgeons grouped their contingencies, with one describing their plan as “stars in my solar system.” (S2). Coming to the OR possessing a predetermined set of responses helps save time and adrenaline, allowing surgeons to act more quickly in times of complications.

Flexibility

Mental 3D visualizations were also described as a tool allowing for flexibility, including shifting effortlessly between the predictable steps of a surgery and dynamic changes. Several of our participants described operating with maximal flow, unhindered by analysis, allowing them to focus their energy on reacting to what is happening in the moment, and maintaining the ability to rearrange the steps as necessary. Proper preparation contributed to this fluidity.

Adaptability to Risk

Our participants described adapting to risk as a “huge skill” (S11), and the “essence of being a good surgeon.” (S1) They described the passion, excitement, and love they had for high-risk surgery as “something like an addiction.” (S12) Another described conducting high-risk surgery as the desire and ability to constantly strive for perfection: “If you aren’t always thinking about precision or making it perfect than you are not doing it right.” (S12) As our surgeons grew in their abilities, they began to trust their plan and develop their skill set for emotional management. Adapting to risk was seen as an aspect of their personality and a strength that drew them to the field. The majority of our participants described adapting to risk as a learned actionable state: “It takes persistence, it takes practice.” (S12) One surgeon noted that, “there is no trick [to adapting to risk], it’s just something you have to develop” (S6), while another noted, “You almost have to have your whole life centered around it.” (S11)

Responsibility & Trusting Your Plan

Our participants emphasized the value of taking responsibility for one’s mistakes. Surgery is inherently risky and “complications are a way of life” (S1), and not a reflection on the individual surgeon. Mistakes, including near misses become valuable when you learn from them: “The second time is what we do best.” (S9) One surgeon described taking complete ownership over complications stating, “it’s not always your fault, but it is always your responsibility.” (S11)

Several participants noted that staying calm is a direct byproduct of trusting the plan that was prepared for each surgery. Having a specific plan, including anticipation of complications helped to avoid panic and irrationality: “The more you anticipate, the better you are going to perform under pressure.” (S12)

Emotional Management

Trusting one’s instincts entails suppressing a wide range of emotions, including denial, anger, and hope. Several of our participants discussed the importance of acknowledging the emotional component during high-risk surgeries: “Feel it but manage it . . .[let] the stress run though you.” (S9) Our participants described adapting to risk as associated with emotional management: “The ability to take the mistakes that you have made, the adrenaline rushes, the confusion, the fear. . .process them, accept them.” (S10)

Humility

Being a surgeon means being humble: “It is called entering into practice, not perfection.” (S7) This involves compassion for self and maintaining humility and taking a “forgive and remember” (S6) approach to mistakes.

Mentorship

Mentorship was key in the development of mental 3D visualization and contingency plans during training years. Our participants’ mentors supplied a safety net that allowed for broader exposure to complex surgical situations, allowing for a calm approach: “The easiest way to not be in over your head is not be there by yourself.” (S4) Our participants adapted to risk by emulating their role models.

Intentionality and Self Reflection

Intentionality and self-reflection were found to be at the core of a surgeon’s surgical resilience. Our participants discussed the danger of overconfidence leading to a lack of introspection. Ignoring mistakes was expressed to be, “equally as bad as beating yourself up.” (S6) As our participants grew in expertise, they reported building a strong foundation of confidence, knowing that they can do it, because they have done it before: “Wisdom comes from making mistakes.” (S8) A conscious choice, self-reflection takes dedication in and out of the OR: “A skill set of what it feels like to have control of yourself. ” (S11).

Member Checking

All participants responding to member checking agreed with our findings. One of our participants discussed the effect of fatigue and team dynamics on preforming under pressure and suggested this as an area of future study. Some of the feedback included comments about the implication of these findings for residency selection and its application for continuing education. One participant drew comparison to John Boyd’s observe–orient–decide–act cycle³¹ for its role in high-risk surgical steps and theorized that this too would benefit from surgical resilience and mental 3D visualization.

DISCUSSION

Mental 3D visualization is pivotal to preoperative preparation and generates contingency plans, which allow for flexibility for managing emotions during high-risk surgery. This visualization exercise entails the surgeon making a 3-D map in their head. These 3D visualized maps inform staying calm under pressure and are essential for building long-term surgical resilience.

Mental 3D visualization requires motor planning, which is associated with changes in the brains of experts and linked with emotional control.²⁶ These changes are present in expert golfers before they even swing the club.²⁶ This skill is developed with repeated exploration of operative zones²⁷ utilizing the brain’s hippocampus, entorhinal cortex, and the frontal lobes.³² In a study that looked at cognitive reconstruction of spaces in individuals that are blind, Lahav et al. found that virtual engagement that involve multiple senses, including haptic sense, built an “overall more holistic and comprehensive” mental map.³³

Other skills developed as a result of contingency plans include personal responsibility, confidence in one’s strategy, and emotional management that culminate in a culture of humility that is utilized in the successful performance of high-risk surgical procedures. Surgery is both mentally and psychologically stressful, and this stress can impact a surgeon’s fine motor skills, coordination, and decision-making abilities.³⁴ These stressors often lead to increased rates of surgeon burnout, particularly among novice surgeons,³⁴ with burnout being an independent factor contributing to surgical error.² A growing problem in the surgical field, professional burnout is reaching epidemic proportions³⁵ and include loss of empathy, emotional fatigue, and a reduced sense of accomplishment.³ Our results suggest that surgeons who avoid burnout do so through building resilience, developed in part by remaining calm in adverse surgical situations.

Our study’s conceptual model (Fig.) illustrates the role mental 3D visualization plays in promoting surgical resilience. The creation of these visualized mental maps are not only an effective method for accelerating the learning curve in helping to combat anxiety over personal competency, but as illustrated in our model of surgical resilience, how self-awareness, emotional management strategies, and a culture of humility are developed.³⁶

The most significant factor differentiating successful and disappointing surgical performance is mental readiness.³⁷ Most surgical errors are attributed to individual factors,³⁸ with lapse of judgment more of a common cause than lack of knowledge.² This suggests interventions targeted at the individual, rather than the system, are more likely to be effective in reducing medical error among surgeons² and reinforces the importance of proper preparation as an effective tool.

Surgical residency is an ideal stage to start developing skills such as mental 3D visualization, preoperative planning, creating contingency plans, and learning to adapt to risk. We recommend that residency curricula take a more deliberate role in teaching mental 3D visualization and foster learning environments that promote successfully adapting to risk. This learning includes teaching skills such as self-reflection, awareness of one’s own tolerance for risk, and building coping skills to manage emotions and mitigate stress.

Limitations

Our participants were White and Asian, which limited our ability to study the lived experience of minority surgeons. We had fewer female than male participants, but this ratio was representative of the surgeons at our hospital. Surgical training programs have been historically white and male, thus it is possible that minority and/or female surgeons experience high-pressure surgery differently than predominantly white, male surgeons. We also did not perform a prospective study. Interviewing surgeons both before and after high-risk surgeries may provide additional information on adapting to risk and mental visualization.

CONCLUSION

Preoperative planning is essential to building resilience for successful performance of high-risk surgery, with mental 3D visualization pivotal for managing stress. Our research raised additional questions for consideration concerning surgical resilience. We suggest that further research be focused on the adverse factors that impact surgical resilience, such as financial or litigation concerns, fatigue, or the effect of team dynamics on successful performance. Additionally, research would benefit from looking directly at a kinesthetic rehearsal in three-dimensional map utilization.