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Push Your Performance to the Next Level: Surgical Performance Optimization

Dimitrios Stefanidis

April 11, 2017

Transcript

- Hello ladies and gentlemen, and thank you for joining us for another session on the doubleness grand rounds. Our guests today's Dr. Dimitrios Stefanidis, he's the Vice Chair of Education at Indiana University Department of Surgery. Who will be talking to us about very unique ideas and methods to push our performance to the next level in the operating room. This is obviously a very important topic for improvement of the quality of the surgeon. And I really thank you for your time, and please go ahead.

- Dr. Cohen, I thank you so much for inviting me and I'm really look forward to share with all our viewers, some of the evidence around how we can improve our performance in surgery. The things that I'm gonna talk about don't only apply to surgery, but it's one way to see the application, how surgeons can apply some of the things we know about performance So these are the learning objectives for this presentation. I would like our viewers to be able to identify the factors impacting acquisition and decay of surgical skill. Discuss the importance of objective performance assessment for performance improvement. Recognize the beneficial effect of feedback on performance and the value of coaching. And also learn some strategies to optimize performance under a variety of conditions. So I think at the very beginning, we need to have a good understanding of how we all, as humans acquire psychomotor skills. It has been known for decades now that typically we acquire skills going through three distinct stages of learning. The first stage is cognitive, the cognitive stage. Essentially you're trying to conceptualize and understand what you're supposed to do. Once you get through that stage, you got to the associative stage where you're really trying to improve in what you're doing. So now you have an understanding of how to do what you're supposed to do, but you're trying to get better than, you're trying to shoot better the free throws let's say in basketball. And then eventually you reach an autonomous stage where a lot of the things that you've learned, because now you've practiced enough, you can do even without giving it a second thought, right? You can do them fairly semi-automatically. So what's also important to understand is that as we learn the learning curve, and as we go through the stages of learning, the learning curve will look something like this, right? So we're gonna start in the cognitive stage. The improvements will be fairly rapid. And then as we transition and get better at what we're doing, the improvements are a lot smaller based on time, but eventually we can achieve a level of performance we wanna be at. It's also important to understand that as we're going through the learning curve of a procedure or a technique or anything that we're learning, each of us goes through that learning curve in different ways. It takes different times, different amounts of time for different divisions to reach a level of performance. And which is depicted in this slide, right? So in this particular situation, let's assume you have procedure X, and you really want the performance of the learner to be at a hundred, and you provide them with training events, right? So they come and do the same case again and again, one, two, three, four, five et cetera times. And you graph their performance over time. But you will see that out of the seven individuals depicted here, each of them will reach the level of performance you want them to reach at a very different timeframe, because we all learn differently, we all come in different shapes and sizes, we all have different abilities of baseline. The problem in our current training paradigm is that we typically define what that length of training has to be just because it's easier to do administratively. But the problem with that approach is that, if you are a bitterness define that time, let's say in this particular case, is seven training events or years of training, then you will get some people who are well-trained, and you will get others who haven't trained enough, they have not reached the level you want them to be at. If you make this again, I return to the shorter, then you live most of the people untrained , or with suboptimal performance. If you make it really long, you will capture the vast majority, but you'll train some too long without a good reason. So the concept of proficiency-based training is based just on what that as I described to you. Instead of setting a particular number of times that somebody needs to do a particular procedure or skill or technique, you say, I don't care about how long it takes you to do this, but I really care about you getting to a performance level that is meaningful and important. So if it is important that a surgeon gets to the level of a hundred, let's say in a particular procedure to do the procedure safely for their patients, that's really what matters to me. Now, it may think different time frames for different individuals to get to that level, but it is important that they all get to that level. So that creates essentially the proficiency-based training paradigm that is tailored to the needs of the individual learner. So according to this, a way to look at the way we acquire expertise in surgery and in medicine in general is what Dreyfus and Dreyfus proposed and is shown in this image, right? So we start as a novice, where we really need the rules to be able to do what you're supposed to do, we need specific guidelines. And then as we progressed through the stages to the advanced beginner, competent practitioner, professional and expert, more and more, we start relying on patterns and experience rather than rules. We just do what works. This is very well documented in the literature. And what we hope to accomplish in our training programs is that when we take the residents, right, the resident after medical school, and we hopefully can bring our residents to the level of being competent, meaning they can accomplish safe procedures. And then perhaps with some sub-specialization, we can get them to the level of proficiency, where they're even better at what they do. And eventually to a level of mastery that comes through practice. I think it is important to also look at the current reality in the context of what I just presented to you. And I would argue that we produce surgeons of variable skill. Do I have any evidence to suggest that? Just look at the literature. A lot of the clinical series that surgeons publish in the literature typically will talk about learning curve. So they say we present your neurosurgeons, right? So we present our experience with the first 200 cases of this brain tumor removal, and our outcomes in the first 50 cases were not as good as the other 150, in the last 150 they were great, the first 50 was a learning curve. Well, the argument I always like to make in that case is why should there be a learning curve if you're a practiced surgeon. You should be already beyond that. You should be at the outcome level of the last 150 cases, not in the first 50. So that is some evidence that the surgeons we produce they're not really the best possible level they need to be to optimize outcomes. It's also true that we know that from surgery, I'm a general surgeon by training, that a lot of our graduating residents pursue fellowships, they don't go into practice directly. To some degree, this is related to them, not feeling ready to go into practice. They wanna do additional training, right? And it has been also my own experience when I've practiced with fellows in minimally invasive bariatric surgery, people who have completed a surgical training, and they're still struggling, even with some basic skills. I think this is a direct consequence of the way we do training, and because we're not really focusing on training on the outcomes of it, but just on the time that we're delivering it. So my view, the prerequisites for optimal skill acquisition are as listed. Number one, the learner has to be internally motivated. They need to want to learn. If they don't have internal motivation, no matter how good a teacher you are, you will never get them to where they need to be. The learners need to come with this. They need to bring that with them. Another important component is that it's really wrong to expose someone who's early in their learning to something very complex. You need to really deconstruct what you're wanting them to learn and deliver it in its easiest, simplest to understand form at the beginning. And gradually as they achieve competence and get better, then you start giving them the more complex scenario, all the food procedure for that matter. Extremely important, and I showed you the data a moment ago, the training needs to be goal-oriented or proficiency-based. They need to define what it is you want them to be able to do upfront, and train them until they reach that level. Not until they get halfway there, until they all get there, if you really wanna produce surgeons who will have the requisite skills to be the most effective and safe. In addition to this, the learner needs to engage in deliberate practice. I'll talk about deliberate practice, a little more in a moment. They also need to have feedback on their performance. And they also need to be able to control themselves independent of the environment they're in. I will focus on these last three points for the rest of my presentation, because I think they're important to understand. So what is deliberate practice? It refers to a form of training that consists essentially of the repetitive, but focused practice in which the learner continuously monitors their performance, and they have the desire to push that performance to the next level, to improve it. And very important component of deliberate practice includes immediate and constant feedback, so they know what areas they need to improve, and what areas they need to practice more to get better at. The man behind the term deliberate factors is Anders Ericsson who's a psychologist in Florida. And he is the one who has interviewed from a variety of domains a lot of masters like in music, in ballet, in chess. And he's come to the conclusion that you may have heard some of this and through different media, like the "Outliers", the book refers to this, that typically people who get really masters in their field who get really good at what they're doing, they take about 10,000 hours of practice, and then routinely practice a lot on a daily basis. So what Ericsson argues is that experience on its own is not good enough to get us to the best possible performance, because many of the daily tasks we do, and we learn through experience like the bike riding, et cetera, right? We may not got to the best possible performance doing it unless we're engaged in deliberate practice, which will allow us to bring our performance closer to that of an expert. In the absence of deliberate practice, in the absence of feedback on our performance, we end up being at a level of arrested development where we perform at a sub-optimal level, without even knowing that we can get better. So talking about feedback, as most of you are aware, it refers to the return of performance related information, essentially to the one doing the performance. And the purpose of feedback is to reinforce the strength. So what is the learner doing well, and what are the areas they need to improve? And by highlighting the difference between they're supposed to be and where they are that can really help them modify their effort, the effort they put in into improving their performance. Feedback is essential for learning because it focuses the attention of the learner to what's really essential and good, and they need to learn. But it's also important to understand that if feedback is not given appropriately, it may actually have the opposite effect and hind their skill acquisition. So we do know from the literature that providing feedback on performance has clearly benefited technical performance. There are studies that demonstrate this in a randomized controlled fashion. That people who get feedback and the being better in their performance after training versus those who don't. And that effect on performance is persistent, even during retention. And I mentioned this briefly a moment ago, that effective feedback needs to be specific, timely and appropriately delivered. So the way we deliver feedback, most of us, and the evidence exists in our literature is that we don't do it well in surgery. So we tend to tell our trainees good job. Well good job doesn't mean much, it just means it's a quick way to feel good about yourself you give feedback on performance, but yet you didn't have to spend much time, right? Because the learner don't doesn't really know what they did good. They don't really know what they didn't do good, and what they need to improve. And it doesn't help. Even if you provide them with some feedback a month later after a performance, they won't remember what it is relevant to. So that's why it's important to be specific, highlight one or two things that you think they did well, and highlight one of the things they need to improve. And that's the best way to provide feedback right after the performance occurred. So in summary, the few references I've listed here demonstrate that have assessed how we provide feedback in surgery have shown that it's rarely specific and timely, but the ones who give the feedback, they typically think they're doing a great job. And actually when you ask the receivers of that feedback, the resident, they don't seem to agree. So another question that I think we need to ask ourselves along the lines of this discussion is, trainees typically will get feedback, whether it's ideal or not. I'm sure there's room for improvement many times. But if you think about faculty, faculty typically do not get any feedback, right? There's a big chasm, once you're done with your training, that feedback loop stops existing. And based on the data presented to you that the risks are staying in the arrested development stage and not farther improving our ability. So we've done a study at the institution I was at before I joined IU few months ago. And we decided to develop a mechanism for coaching of practicing surgeons that was based on objective performance assessment. So coaching is a form of feedback, but there's some differences. What it does, is it sets goals and provides through an interaction one-on-one interaction with a coach, it provides you feedback on whether you are achieving the goals and how you can get there. There's a great book that if you're interested in this topic you should read. And this is by Alan Fine, and it's called "You Already Know How to Be Great". And what Alan Fine argues is that we all know how to really be good, but just need to focus on how to get there. And he argues that the elements of really performance improvements are number one, their faith in your abilities to be focused on what you're trying to do, and do you have fire, do you have the desire to get better. And the knowledge is part of all this, but knowledge is really the main thing that is emphasized by our educational system, but it's not really the most important element. And when you do coaching, you define goals, then you reflect on the reality by performance assessment, you see where you're currently at, and then you determine how can I get where I wanna get. You consider the options, pick the one that you're gonna move forward with, the best one. Is coaching effective? If you look at the systematic reviews that they have assessed, coaching compared to other modes of training and education, like a workshop or practicing versus coaching, or traditional professional development, the effectiveness of coaching has been shown to be significantly more than that of traditional professional development. If you look at surgery specifically, and a lot of this evidence really comes from general surgery, however, it clearly applies to any type of surgery in my opinion, It has been shown that coaching has improved perceptions and attitudes, technical skills, non-technical skills, performance measures, and it has been proven effective with medical students, residents and practicing surgeons. And typically what you will see, this is from one of the studies listed here is that if you don't do coaching the performance maybe here and after coaching, it goes really significantly up and persists over time. So in the study we did, we took 32 practicing surgeons from seven different hospitals. We recorded three procedures. These were general surgeons and gynecologists. And we looked at laparoscopic cholecystectomy, colectomy, and hysterectomy. And these were both laparoscopic or robotic versions. And we assessed both the technical performance, as well as non-technical performance. Non-technical performance we refer to typically as leadership, teamwork, communication, situation, awareness, et cetera. And what we did is we looked at the videos, assess them. And then we had the expert surgeons look at the technical videos, human factors, experts look at the non-technical videos. And then we met with the surgeons and we provide them with feedback and did the reassessment after that intervention. We also use simulation for them to practice. So this is what our coaching model look like. We assess the skill of surgeons through video. We identified areas of improvement we then hand some group and individual sessions that we highlighted the issues that were identified. We show them videos. We have them identify what they were doing, but perhaps one of the issues and the deficiencies, and they picked up on the issues. All these videos were blinded, they didn't know who they were watching, but they were very good about picking up the problems, even though it could have been themselves doing the procedure, you couldn't tell. And we also put them through scenarios in the operating room environment, where we actually introduced distractions and try to stress them out, to see how they would respond. We brought them back. We offered them the opportunity for practice. And then we also included a component of patient outcome monitoring. And then the circle completes after that. And you keep going until you achieve your initial objective. So we actually identify the number of issues that could be improved, whether that was related to port placement for laparoscopy, whether that was related to exposure or retraction, how could have been done better than what was shown in the video, visualization, some decision-making. To give an example, there was a case where the surgeon was doing a colectomy and got into some bleeding, and it took them a while to really make the appropriate decision of how to best do this, instead of, putting a sponge in, perhaps in controlling it, and then consider what the best way to do this, they kept digging themselves in the groove essentially so. And that wasn't really ideal. So that's what that was I was referring as decision-making issues. But we even identified issues with bimanual dexterity. That should be better than it was actually. And also adherence to safe practices. To give another example here, when you do, for example, a hysterectomy, one of the biggest risks is you can injure the ureters because the ureters run right under the uterus. So the best way to prevent problems is if you look for the ureters while you're trying to remove the uterus. We had surgeons who were looking to find the ureters after they had removed the uterus. Well, at that point, you may identify the injury, but sorry, too late, right? So that's not really a good, safe practice. So there's a couple of videos that was demonstrating some of the problems, but we'll skip over them in the interest of time. We encountered some challenges like with engagement, there were some surgeons who were concerned that this was like a big brother watching me, if they find them not good at something, they will fire me or something along those lines. This was all done with the tend to be peer reviewed and to have peers help ourselves get better. It was resource intensive and costly, and it was a significant time investment. Surgeons as I mentioned, some worried about appearing competent or concerned about losing autonomy. Some they didn't even think they need to improve. I can tell you that based on what we saw, most everybody had room for improvement. So this sums up what I had to, but I wanted to share with you in regards to, how we can better the power of coaching, which is actually increasingly being utilized in surgery today. And it's something, if you are not doing, you should definitely start considering. But I'm gonna talk a little more about managing self and environment. And what I mean by that. So you may have heard this adage that actually was said by a surgeon, Dr. Spencer in 1978, who said that, "A skillfully performed operation is about 75% decision-making and 25% dexterity." And the evidence behind that statement is zero. Sorry, Dr. Spencer, but I'm not really a believer in this because they're no evidence. What we do know, however, is that failures in non-technical skills, especially situational awareness among surgeons are associated with higher rates of technical errors. And that there's a strong correlation between teamwork disruptions and surgical errors. And I want to bring your attention to your attention. And the reason for that is because your attention is like a cup that has a limited capacity. And if there's too much information that comes in, right, our working memory is limited. If there's too much information that comes into it, at some point, it will overflow, it will fill up the cup and it will overflow. In other words, you start missing important information. And if that information is critical for your patient, that can lead to problems. So it's important to understand that concept. And the way this ties into what I introduced to you earlier, the learning, is that as we go through the stages of learning our attentional capacity changes. In other words, when we're first trying to learn a new procedure, most of the attentional capacity is used. And if the procedure is very complex, we don't have enough attentional capacity to devote to everything that that procedure may require. Best example for all of you who have worked with trainees early on in their learning is you're trying to talk to a training to tell them what to do, and they seem that they're not listening to you. And their typical knee jerk response of most practice surgeons is to scream at the trainee to get their attention, right? Well the reason they don't listen to you, typically is not because they don't like you, it's not because they don't wanna pay attention to you, is that they cannot listen to you. Their attention capacity is overwhelmed, and your talking is beyond, it's outside of that cup. They cannot listen, so you have to interrupt them to be able to get their attention to you, to be able to communicate to them. As we transition, however, through the stages of learning, we go to be associative stage. So now we start having some spare capacity because we're getting more comfortable with a task. And we don't need to devote all our attention to everything, right? And then as we get to the autonomous stage, we may actually have most of our attentional capacity free to also hold a conversation, to pay attention the vital signs of the patient, to ask the nurse to bring us something important for the care of the patient to coordinate the anesthesia, right? So all those things are important to understand. And the reason understand this is because it doesn't only apply to novice learners. This also applies to experienced surgeons when they, perhaps engaged in doing a new procedure that don't have experience with, their learning ability shifts back to this stage, the cognitive stage, and they're subject to the same limitations, which is important for patient safety. So we can measure spare attentional capacity actually, there are ways that you can do to the secondary tasks. And we applied that methodology in a previous study where we're demonstrating that if, so essentially what we did is we had our participants do laparoscopic surgery. So there were using long instruments to suture laparoscopically, but at the same time on their view screen, we super-imposed another task that they were required to attend to using their foot, through a foot pedal. And that task, if you do it alone is very simple. So they have just recognize when a square was blinking on the screen three times consecutively on the right side of the screen, but it could be on both sides, either side, it could be blink twice or three times is other. So they only had to respond by pushing the foot pedal when they were seeing it on the right side of the screen. Well that allows you to do is assess that spare attention capacity, which is a measure of expertise and automaticity, as I mentioned, right? So it doesn't interfere with your hands. You can still use them and do the primary task. But it lets us assess what that ability is. And what we found was that by doing this, actually, we were able to better assess when residents were better trained in a simulation environment before the transition to a clinical environment. Because when we brought them to the clinical environment in a simulated OR, those who had achieved higher levels of automaticity performed better clinically. So going back to the issue of attention, and I mentioned this a moment ago, I think if you look at how most of us do teaching in the operating room, we're fairly ineffective because we don't really understand a lot of the concepts that are presented. So one of the things that recently came out in the literature, which really resonates with me and what I just presented to you. There's a group of physicians from Great Britain who were tasked by the British government to assess ways to improve adaptation or adoption, I should say of laparoscopic colectomy by general surgeons in the UK. Why? Because their benefits, patients go home sooner. It's minimally invasive techniques, right? So it would save the system money, and not many surgeons were doing it. So when they started looking at ways to improve that adoption rate, they had colorectal surgeons, but also psychologists involved, they fairly quickly realized that most surgeons did not know how to teach in the open room. And based on what I mentioned to you about the issues with spare attention capacity and learning stage, they proposed this, what you're seeing on your screen, which is essentially when you wanna teach someone in the operating room, the first thing you need to do is stop them what they're doing. So they can divert their attention to you and really understand what you're trying to tell them. Then the first thing you need to do is ask them, why you stopped them to see if they're aware of what's happening and what the problem might be. You might not be happy with the area they're dissecting at, let's say. You may not be happy as they attending with something else. But you need to ask them first, are they aware of why you stopped them, you're not happy with. And then whether they are or not, you explain why you stop them. You instruct them as the next step, how to do things better. You check if they understood what you told them, you ask them to repeat. And then you judge based on what your assessment is or what you hear from them, if they're good to move on with what they were doing, or if you need to take over. And this is really I think a training paradigm of intraoperative teaching that can definitely improve dramatically the effectiveness of our teaching in the operating room and teaching sort of in general. And actually these investigators have done a series of studies that have shown that using this paradigm, they have improved significantly performance of surgeons. So another aspect that we need to be familiar with is that our attention is selective. And sometimes we see different things than what we wanna see. Heuristics, this is not as heuristics where essentially, especially if you're an expert, I mentioned earlier, we work by partner recognition and quick decision-making. But when we do this, we take shortcuts because that saves time. But sometimes those shortcuts can be a trap. And that's where the heuristics comes in. So in this particular situation, some of you may see the chalice, and some of you may see two faces, well they're both there. But depends on what you focus on. you may miss the other one. This is what has been described, for example, to happen during laparoscopic cholecystectomy. Because one of the risks is you may or may not know the laparoscopic cholecystectomy is bile duct injuries, the don't happen often, but they keep happening despite the technology being so advanced nowadays. And usually what happens is when you lift the gal bladder the way we do, the technique, we expect to see the cystic duct, which is what we need to divide to be the one that would lift on. But we don't necessarily anticipate that we may be lifting the main bile duct, and that may be diving down, further down, so if we divide here, we're gonna injure it. So there are different things that need to be used to minimize that issue. Switching gears, another important aspect of performance that we need to discuss is the effect of stress. We all need some level of stress or perhaps arousal is a better description to be able to function well. If you're laying down on your couch, you're probably not in the best state for performance. At the same time however, if you overly stressed as most of you can probably recall, you're not in the best shape to have your optimal performance either. So for all humans, there's a comfort zone where we work in a function ideally, or we can have our best performance. That is when there's a level of arousal, but the level is not overly excessive to the point that it leads to performance deterioration. And we do know that when this arousal level of distress, reaches a point that we cannot take any longer, our performance deteriorates dramatically. And this is an extremely important for us surgeons because we are often in very stressful situations. As a neurosurgeon, no question, right? So you deal with the brain, you can have devastating effects by making a mistake on patients. So that causes a lot of stress. So being able to manage that stress so that you don't reach the level where the performance deteriorates can be very valuable, because what the stress management techniques can do is they can elevate that threshold so you can work better even at higher level of stress. So this is referred to as ideal performance state, right? So we wanna be at the state where we function the best, where our performance is not inhibited because we don't have enough arousal, and our performance is not inhibited because we have over arousal, just emphasize the previous point. And that's where mental skills training comes in. Mental skills are essentially a set of trainable abilities that can help performers achieve that ideal state, where they perform the best. And they can include a number of things that I'm gonna show you. Many of these skills we all develop with experience over time. The problem is that we don't necessarily develop them in the best possible way. And we may never develop some of them because we don't really get specific training on them. So our group has worked and developed a curriculum along those lines. It's been funded by the Agency for Healthcare Research and Quality. And we have implemented it with our residents at two institutions. Currently, we're doing it here at IU as well. And have demonstrated its effectiveness. And what this does essentially is we focus on mental imagery. Mental imagery, most of you probably do and especially if you have experience with surgery is when you play in your head, the procedure, how it's gonna go before you do the procedure, that lets you better prepare, even for the unexpected events, what will happen if I start having bleeding, I'm gonna do this, right? So that is a very powerful way of performance, preparation and improvement. We have goal setting. I talked about goals before. It's always very important to have goals that you set for yourself. About energy management. So there are ways that you can bring your arousal level down if it's extremely elevated, and you're afraid you're gonna reach the threshold of performance duration, but there are also ways that you can bring your energy level up if you feel really that it's down and you're fatigued, for example. There's strategies, how to best manage your attention. So you don't fall in the traps that I showed you earlier. And also refocusing strategies meaning what to give an example. If you run into a bad situation, oftentimes my experience has been, you will start thinking, oh my God, what's gonna happen, now gonna have to explain to the family that this went wrong, and this patient may be in the hospital now forever. And this problem may arise and this, you keep having what is called negative self-talk. And that can only make your performance worse. Refocusing strategies teach you ways that when you get into that situation, you divert your attention back to positive thinking you say okay, this way I will deal later with, right now, I just need to focus on what's important to make sure we don't create any more problems, for example. And also they have some performance routines that you do specifically before you start the case that brings your performance to the best possible level. So these are some goals of our department. And I will finish this presentation with some take home points. So number one, deliberate practice is essential to improve skills. Number two, proficiency based training is superior to traditional training as we're doing it, which is time-based. Number three, coaching significantly can improve performance. And also that understanding what the limitations of our attention are, can help us acquire skills better and faster and become safer surgeons. And you should also be aware that there are strategies, that can help you optimize performance and control stress, and other factors, distractions that are trainable. And I think we'll see a lot more of these moving forward, being implemented more and more in training. I'll be happy to take any questions. Thank you, Dr. Cohen.

- Dimitrios, thanks for really a very worthwhile talk. Something that is extremely useful sometimes often for granted, but definitely can affect education specifically for our trainees as well as junior faculty. So putting all these together, how would you apply that to let's say my program or your program, how would you create an infrastructure let's say to take advantage of these useful concepts to improve the program?

- Thank you for the question Dr. Cohen. So I think that a number of ways that some of these practices can be incorporated into a surgical department, training program, neurosurgical, I think all these concepts, as I mentioned a moment ago, apply to all surgeons is not specific to a specialty. So the way we're doing it in the department of surgery here in general surgery is we do have a coaching program in place for our faculty, okay. And what we're doing is we're asking our faculty, we would pick a procedure, let's say. Let's say I do my practices, a big proportion of it is bariatric surgery, right? So we took, let's say the gastric bypass, and we're gonna record a case, video record it all of us because all of the partners do that, right? And then we'll peer review those videos without knowing a surgeon who is doing it. We have an assessment and we'll write down what the areas of improvement there are of the surgeon we're looking at. And then we'll unblind it. And then we'll have coaching sessions where we'll meet with each other, it's like a peer learning, right? So we're gonna say, okay, you could do this, you should do this a little bit different considering this considering that, or maybe everything is fine, okay. The other aspect as I presented is, we're gonna have some human factors collaborators of us be in the operating room so that they can provide their perspective as to what surgeons could do differently from a non-technical aspect, right? Forget the technical performance, but how they interact, how they communicate, how they lead the team, cetera, if there is room for improvement. And they would meet with that coach to give them that feedback. And the other thing we also gonna do, because we are in academic practice obviously at IU is, we will also ask the same surgeons to record another procedure where they're taking a trainee through the procedure. And the focus of that will be to assess their teaching of the trainee. So then we'll meet again and we'll go over whether it was done well or what areas for improvement they have. And so then we'll assess, we'll keep doing this every three months, right? We'll reassess and then we'll see if the new video that we watch now suddenly all the issues have been addressed and it looks a lot better, we've achieved our goal we moved to a different procedure. And we keep going. If we haven't achieved our goal, then when a focus again, with the same surgeon we say, okay, this is where we think you should get better. Let's focus on this, let's practice on this. And then, as you know, if you don't know what you need to get better at, you are unlikely to improve. If somebody brings it to your attention, even though you may be the best of the best, okay? If somebody tells you, hey, consider doing this a little bit differently You're smart, we're all smart. I bet you, you will change behavior, because you may see, well, they're right, I can do this easier, better, et cetera. That's the power I think of coaching and peer learning. Because when we did this previously, at a previous institution, I had a number of surgeons who said, I like that technique I saw, I'll be using that too, for example. Or some other says, oh my God, that was terrible. No different story, right. But I mean that's what you'll get from something like this. So this is like for faculty. For trainees you can do the same thing, but you can also in regards to mental skills, what we're doing is we have a coach who works with them, and who has the regular sessions at early in their training and then teaches them those techniques I mentioned in my presentation, mental imagery, setting goals, performance routines, refocusing strategies, et cetera. And he has them apply laws techniques during learning on simulators, because one thing is to teach you something, and another thing is to apply, right? So that's really what matters, if you get the theory and you started using it. So we were combining essentially both elements, and we have them learn how, let's say to suture laparoscopically. We put them under some stressful conditions too in the lab to see how they respond. That's how we've been doing this.

- I really like the discussion about the faculty and the coaching and having each other reviewing your videos. However, as you know, most of the departments don't have such a collegial environment where the faculty objectively look at each other's videos, often they could have personal agendas, and it's unfortunate that this occurs, but it's reality of life. How do you deal with those conditions and those circumstances?

- And that's a great question. There's no question that this will always be an issue, right? I think the way I've always approached this, and to be able to also do it previously, has been, you know, we're here because we wanna serve our patients, and offer them the best possible operation and care, correct? Anything that will make me better, I wanna know about it, because I wanna be the best I can be. And if I'm the one driving this, I always make that argument, I wanna be couched, I wanna learn, I wanna get better. I'm not doing this to reprimand my junior people because I'm senior to them and I know everything, they don't know nothing, right. That will never work. So this is one. I mean, the other thing is that this has to be done, there's no question about this, everybody needs to understand that this is for improvement, this is not meant to be judgemental or negative. We all have room for improvement. So it needs to be not frightening to people. We need to leave our ego aside a little, yeah that's the answer to your question to get better.

- Yeah and I sure definitely hope that that will be a reality one day in the neurosurgery departments across the country, because obviously we have to put the interest of the patient first, rather than our personal agendas, or necessarily our competitive behaviors. But nonetheless, I really enjoyed it. I think it's critical to pay attention to these details in terms of improving our skills and remembering these basic principles that definitely guide evolution of techniques to our time. So on behalf of all the other neurosurgeons, watching this video, Dimitrios thank you again. And will look forward to seeing you again for another session.

- Thank you so much for inviting me and giving me the opportunity to present some of our work.

- You're welcome.

- Thank you for that.

- Thank you.

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