Temporal Stress in the Operating Room: Brain Engagement Promotes "Coping" and Disengagement Prompts "Choking"

Using neuroimaging to assess brain activity and areas associated with surgical skills: a systematic review

BACKGROUND

Surgical skills acquisition is under continuous development due to the emergence of new technologies, and there is a need for assessment tools to develop along with these. A range of neuroimaging modalities has been used to map the functional activation of brain networks while surgeons acquire novel surgical skills. These have been proposed as a method to provide a deeper understanding of surgical expertise and offer new possibilities for the personalized training of future surgeons. With studies differing in modalities, outcomes, and surgical skills there is a need for a systematic review of the evidence. This systematic review aims to summarize the current knowledge on the topic and evaluate the potential use of neuroimaging in surgical education.

METHODS

We conducted a systematic review of neuroimaging studies that mapped functional brain activation while surgeons with different levels of expertise learned and performed technical and non-technical surgical tasks. We included all studies published before July 1st, 2023, in MEDLINE, EMBASE and WEB OF SCIENCE.

RESULTS

38 task-based brain mapping studies were identified, consisting of randomized controlled trials, case-control studies, and observational cohort or cross-sectional studies. The studies employed a wide range of brain mapping modalities, including electroencephalography, functional magnetic resonance imaging, positron emission tomography, and functional near-infrared spectroscopy, activating brain areas involved in the execution and sensorimotor or cognitive control of surgical skills, especially the prefrontal cortex, supplementary motor area, and primary motor area, showing significant changes between novices and experts.

CONCLUSION

Functional neuroimaging can reveal how task-related brain activity reflects technical and non-technical surgical skills. The existing body of work highlights the potential of neuroimaging to link task-related brain activity patterns with the individual level of competency or improvement in performance after training surgical skills. More research is needed to establish its validity and usefulness as an assessment tool.

Surgical Sabermetrics: A Scoping Review of Technology-enhanced Assessment of Nontechnical Skills in the Operating Room

OBJECTIVE

To evaluate the current evidence for surgical sabermetrics: digital methods of assessing surgical nontechnical skills and investigate the implications for enhancing surgical performance.

BACKGROUND

Surgeons need high-quality, objective, and timely feedback to optimize performance and patient safety. Digital tools to assess nontechnical skills have the potential to reduce human bias and aid scalability. However, we do not fully understand which of the myriad of digital metrics of performance assessment have efficacy for surgeons.

METHODS

A systematic review was conducted by searching PubMed, EMBASE, CINAHL, and PSYCINFO databases following PRISMA-ScR guidelines. MeSH terms and keywords included "Assessment," "Surgeons," and "Technology". Eligible studies included a digital assessment of nontechnical skills for surgeons, residents, and/or medical students within an operative context.

RESULTS

From 19,229 articles screened, 81 articles met the inclusion criteria. The studies varied in surgical specialties, settings, and outcome measurements. A total of 122 distinct objective, digital metrics were utilized. Studies digitally measured at least 1 category of surgical nontechnical skill using a single (n=54) or multiple objective measures (n=27). The majority of studies utilized simulation (n=48) over live operative settings (n=32). Surgical Sabermetrics has been demonstrated to be beneficial in measuring cognitive load (n=57), situation awareness (n=24), communication (n=3), teamwork (n=13), and leadership (n=2). No studies measured intraoperative decision-making.

CONCLUSIONS

The literature detailing the intersection between surgical data science and operative nontechnical skills is diverse and growing rapidly. Surgical Sabermetrics may provide a promising modifiable technique to achieve desirable outcomes for both the surgeon and the patient. This study identifies a diverse array of measurements possible with sensor devices and highlights research gaps, including the need for objective assessment of decision-making. Future studies may advance the integration of physiological sensors to provide a holistic assessment of surgical performance.

Optimizing Human-Robot Teaming Performance through Q-Learning-Based Task Load Adjustment and Physiological Data Analysis

The transition to Industry 4.0 and 5.0 underscores the need for integrating humans into manufacturing processes, shifting the focus towards customization and personalization rather than traditional mass production. However, human performance during task execution may vary. To ensure high human-robot teaming (HRT) performance, it is crucial to predict performance without negatively affecting task execution. Therefore, to predict performance indirectly, significant factors affecting human performance, such as engagement and task load (i.e., amount of cognitive, physical, and/or sensory resources required to perform a particular task), must be considered. Hence, we propose a framework to predict and maximize the HRT performance. For the prediction of task performance during the development phase, our methodology employs features extracted from physiological data as inputs. The labels for these predictions-categorized as accurate performance or inaccurate performance due to high/low task load-are meticulously crafted using a combination of the NASA TLX questionnaire, records of human performance in quality control tasks, and the application of Q-Learning to derive task-specific weights for the task load indices. This structured approach enables the deployment of our model to exclusively rely on physiological data for predicting performance, thereby achieving an accuracy rate of 95.45% in forecasting HRT performance. To maintain optimized HRT performance, this study further introduces a method of dynamically adjusting the robot's speed in the case of low performance. This strategic adjustment is designed to effectively balance the task load, thereby enhancing the efficiency of human-robot collaboration.

Distinguishing Laparoscopic Surgery Experts from Novices Using EEG Topographic Features

The study aimed to differentiate experts from novices in laparoscopic surgery tasks using electroencephalogram (EEG) topographic features. A microstate-based common spatial pattern (CSP) analysis with linear discriminant analysis (LDA) was compared to a topography-preserving convolutional neural network (CNN) approach. Expert surgeons (N = 10) and novice medical residents (N = 13) performed laparoscopic suturing tasks, and EEG data from 8 experts and 13 novices were analysed. Microstate-based CSP with LDA revealed distinct spatial patterns in the frontal and parietal cortices for experts, while novices showed frontal cortex involvement. The 3D CNN model (ESNet) demonstrated a superior classification performance (accuracy > 98%, sensitivity 99.30%, specificity 99.70%, F1 score 98.51%, MCC 97.56%) compared to the microstate based CSP analysis with LDA (accuracy ~90%). Combining spatial and temporal information in the 3D CNN model enhanced classifier accuracy and highlighted the importance of the parietal-temporal-occipital association region in differentiating experts and novices.

Spinal Navigation for Lateral Instrumentation of the Thoracolumbar Spine

BACKGROUND AND OBJECTIVES

Three-dimensional imaging-based navigation in spine surgery is mostly applied for pedicle screw placement. However, its potential reaches beyond. In this study, we analyzed the incorporation of spinal navigation for lateral instrumentation of the thoracolumbar spine in clinical routine at a high-volume spine center.

METHODS

Patients scheduled for lateral instrumentation were prospectively enrolled. A reference array was attached to the pelvis, and a computed tomography scan was acquired intraoperatively. A control computed tomography scan was routinely performed after final cage placement, replacing conventional 2-dimensional X-ray imaging.

RESULTS

145 cases were enrolled from April to October 2021 with a median of 1 (1-4) level being instrumented. Indications for surgery were trauma (35.9%), spinal infection (31.7%), primary and secondary tumors of the spine (17.2%), and degenerative spine disease (15.2%). The duration of surgery after the first scan was 98 ± 41 (20-342) minutes. In total, 190 cages were implanted (94 expandable cages for vertebral body replacement (49.5%) and 96 cages for interbody fusion [50.5%]). Navigation was successfully performed in 139 cases (95.9%). The intraoperative mental load was rated on a scale from 0 to 150 (maximal effort) by the surgeons, showing a moderate effort (median 30 [10-120]).

CONCLUSION

Three-dimensional imaging-based spinal navigation can easily be incorporated in clinical routine and serves as a reliable tool to achieve precise implant placement in lateral instrumentation of the spine. It helps to minimize radiation exposure to the surgical staff.

A scoping review of emotions and related constructs in simulation-based education research articles

BACKGROUND

While acknowledgement of emotions' importance in simulation-based education is emerging, there are concerns regarding how education researchers understand the concept of emotions for them to deliberately incorporate emotionally charged scenarios into simulation-based education. This concern is highlighted especially in the context of medical education often lacking strong theoretical integration. To map out how current simulation-based education literature conceptualises emotion, we conducted a scoping review on how emotions and closely related constructs (e.g. stress, and emotional intelligence) are conceptualised in simulation-based education articles that feature medical students, residents, and fellows.

METHODS

The scoping review was based on articles published in the last decade identified through database searches (EMBASE and Medline) and hand-searched articles. Data extraction included the constructs featured in the articles, their definitions, instruments used, and the types of emotions captured. Only empirical articles were included (e.g. no review or opinion articles). Data were charted via descriptive analyses.

RESULTS

A total of 141 articles were reviewed. Stress was featured in 88 of the articles, while emotions and emotional intelligence were highlighted in 45 and 34 articles respectively. Conceptualisations of emotions lacked integration of theory. Measurements of emotions mostly relied on self-reports while stress was often measured via physiological and self-report measurements. Negative emotions such as anxiety were sometimes seen as interchangeable with the term stress. No inferences were made about specific emotions of participants from their emotional intelligence.

CONCLUSIONS

Our scoping review illustrates that learners in simulation-based education are most often anxious and fearful. However, this is partially due to medical education prioritising measuring negative emotions. Further theoretical integration when examining emotions and stress may help broaden the scope towards other kinds of emotions and better conceptualisations of their impact. We call for simulation education researchers to reflect on how they understand emotions, and whether their understanding may neglect any specific aspect of affective experiences their simulation participants may have.

Unpacking the Broad Landscape of Intraoperative Stressors for Clinical Personnel: A Mixed-Methods Systematic Review

Purpose

The main goals of this mixed-methods systematic review are to identify what types of intraoperative stressors for operating room personnel have been reported in collected studies and examine the characteristics of each intraoperative stressor.

Methods

With a systematic literature search, we retrieved empirical studies examining intraoperative stress published between 2010 and 2020. To synthesize findings, we applied two approaches. First, a textual narrative synthesis was employed to summarize key study information of the selected studies by focusing on surgical platforms and study participants. Second, a thematic synthesis was employed to identify and characterize intraoperative stressors and their subtypes.

Results

Ninety-four studies were included in the review. Regarding the surgical platforms, the selected studies mainly focused on minimally invasive surgery and few studies examined issues around robotic surgery. Most studies examined intra-operative stress from surgeons' perspectives but rarely considered other clinical personnel such as nurses and anesthetists. Among seven identified stressors, technical factors were the most frequently examined followed by individual, operating room environmental, interpersonal, temporal, patient, and organizational factors.

Conclusion

By presenting stressors as multifaceted elements affecting collaboration and interaction between multidisciplinary team members in the operating room, we discuss the potential interactions between stressors which should be further investigated to build a safe and efficient environment for operating room personnel.

[Assessment method of cognitive load and stress inducer factors of surgeons and anesthetists in the operating room]

INTRODUCTION

For many years, surgeons and anesthetists have recognized that stress can be present in their daily professional practice. The goal of this study was to identify tools for assessing stress and cognitive load in the operating room.

MATERIAL AND METHODS

We conducted a literature review in the PubMed database of scientific articles published on the subject without date limit using the keywords anesthesia, surgery, surgeon, cognitive workload, definition, pathophysiology, physiological measurement, objective, subjective, stress.

RESULTS

Nineteen articles were selected, focusing on cardiac surgery, gastrointestinal surgery, vascular surgery and urology. No publications concerning ophthalmology were found through the literature search. The means of measurement found were either subjective, such as questionnaires, or objective, such as the study of heart rate variability (HRV), reaction time, eye movements, electrical conductivity of the skin, biological markers and electroencephalogram. Of all these measurement tools, the NASA-TLX questionnaire, used in four articles, and the HRV study, used in eight articles, appear to be the most widely used and are strongly correlated with stress.

CONCLUSION

The articles reviewed use only some of the available tools for assessment of stress and cognitive load. The main objective is to improve the quality of care and the quality of life of caregivers. It would be interesting to develop other methods to identify and better characterize the risk factors that increase stress and cognitive load.

Optical neuroimaging and neurostimulation in surgical training and assessment: A state-of-the-art review

Introduction

Functional near-infrared spectroscopy (fNIRS) is a non-invasive optical neuroimaging technique used to assess surgeons' brain function. The aim of this narrative review is to outline the effect of expertise, stress, surgical technology, and neurostimulation on surgeons' neural activation patterns, and highlight key progress areas required in surgical neuroergonomics to modulate training and performance.

Methods

A literature search of PubMed and Embase was conducted to identify neuroimaging studies using fNIRS and neurostimulation in surgeons performing simulated tasks.

Results

Novice surgeons exhibit greater haemodynamic responses across the pre-frontal cortex than experts during simple surgical tasks, whilst expert surgical performance is characterized by relative prefrontal attenuation and upregulation of activation foci across other regions such as the supplementary motor area. The association between PFC activation and mental workload follows an inverted-U shaped curve, activation increasing then attenuating past a critical inflection point at which demands outstrip cognitive capacity Neuroimages are sensitive to the impact of laparoscopic and robotic tools on cognitive workload, helping inform the development of training programs which target neural learning curves. FNIRS differs in comparison to current tools to assess proficiency by depicting a cognitive state during surgery, enabling the development of cognitive benchmarks of expertise. Finally, neurostimulation using transcranial direct-current-stimulation may accelerate skill acquisition and enhance technical performance.

Conclusion

FNIRS can inform the development of surgical training programs which modulate stress responses, cognitive learning curves, and motor skill performance. Improved data processing with machine learning offers the possibility of live feedback regarding surgeons' cognitive states during operative procedures.

The neurophysiology of intraoperative error: An EEG study of trainee surgeons during robotic-assisted surgery simulations

Surgeons operate in mentally and physically demanding workspaces where the impact of error is highly consequential. Accurately characterizing the neurophysiology of surgeons during intraoperative error will help guide more accurate performance assessment and precision training for surgeons and other teleoperators. To better understand the neurophysiology of intraoperative error, we build and deploy a system for intraoperative error detection and electroencephalography (EEG) signal synchronization during robot-assisted surgery (RAS). We then examine the association between EEG data and detected errors. Our results suggest that there are significant EEG changes during intraoperative error that are detectable irrespective of surgical experience level.

Electroencephalography can provide advance warning of technical errors during laparoscopic surgery

BACKGROUND

Intraoperative adverse events lead to patient injury and death, and are increasing. Early warning systems (EWSs) have been used to detect patient deterioration and save lives. However, few studies have used EWSs to monitor surgical performance and caution about imminent technical errors. Previous (non-surgical) research has investigated neural activity to predict future motor errors using electroencephalography (EEG). The present proof-of-concept cohort study investigates whether EEG could predict technical errors in surgery.

METHODS

In a large academic hospital, three surgical fellows performed 12 elective laparoscopic general surgeries. Audiovisual data of the operating room and the surgeon's neural activity were recorded. Technical errors and epochs of good surgical performance were coded into events. Neural activity was observed 40 s prior and 10 s after errors and good events to determine how far in advance errors were detected. A hierarchical regression model was used to account for possible clustering within surgeons. This prospective, proof-of-concept, cohort study was conducted from July to November 2021, with a pilot period from February to March 2020 used to optimize the technique of data capture and included participants who were blinded from study hypotheses.

RESULTS

Forty-five technical errors, mainly due to too little force or distance (n = 39), and 27 good surgical events were coded during grasping and dissection. Neural activity representing error monitoring (p = .008) and motor uncertainty (p = .034) was detected 17 s prior to errors, but not prior to good surgical performance.

CONCLUSIONS

These results show that distinct neural signatures are predictive of technical error in laparoscopic surgery. If replicated with low false-alarm rates, an EEG-based EWS of technical errors could be used to improve individualized surgical training by flagging imminent unsafe actions-before errors occur and cause patient harm.

Use of neuroimaging to measure neurocognitive engagement in health professions education: a scoping review

PURPOSE

To map the current literature on functional neuroimaging use in medical education research as a novel measurement modality for neurocognitive engagement, learning, and expertise development.

METHOD

We searched PubMed, Embase, Cochrane, ERIC, and Web of Science, and hand-searched reference lists of relevant articles on April 4, 2019, and updated the search on July 7, 2020. Two authors screened the abstracts and then full-text articles for eligibility based on inclusion criteria. The data were then charted, synthesized, and analyzed descriptively.

RESULTS

Sixty-seven articles published between 2007 and 2020 were included in this scoping review. These studies used three main neuroimaging modalities: functional magnetic resonance imaging, functional near-infrared spectroscopy, and electroencephalography. Most of the publications (90%, n = 60) were from the last 10 years (2011-2020). Although these studies were conducted in 16 countries, 68.7% (n = 46) were from three countries: the USA (n = 21), UK (n = 15), and Canada (n = 10). These studies were mainly non-experimental (74.6%, n = 50). Most used neuroimaging techniques to examine psychomotor skill development (57%, n = 38), but several investigated neurocognitive correlates of clinical reasoning skills (22%, n = 15).

CONCLUSION

This scoping review maps the available literature on functional neuroimaging use in medical education. Despite the heterogeneity in research questions, study designs, and outcome measures, we identified a few common themes. Included studies are encouraging of the potential for neuroimaging to complement commonly used measures in education research and may help validate/challenge established theoretical assumptions and provide insight into training methods. This review highlighted several areas for further research. The use of these emerging technologies appears ripe for developing precision education, establishing viable study protocols for realistic operational settings, examining team dynamics, and exploring applications for real-time monitoring/intervention during critical clinical tasks.

Stress in surgical educational environments: a systematic review

BACKGROUND

The effects of stress on surgical residents and how stress management training can prepare residents to effectively manage stressful situations is a relevant topic. This systematic review aimed to analyze the literature regarding (1) the current stress monitoring tools and their use in surgical environments, (2) the current methods in surgical stress management training, and (3) how stress affects surgical performance.

METHODS

A search strategy was implemented to retrieve relevant articles from Web of Science, Scopus, and PubMed. The 787 initially retrieved articles were reviewed for further evaluation according to the inclusion/exclusion criteria (Prospero registration number CRD42021252682).

RESULTS

Sixty-one articles were included in the review. The stress monitoring methods found in the articles showed heart rate analysis as the most used monitoring tool for physiological parameters while the STAI-6 scale was preferred for psychological parameters. The stress management methods found in the articles were mental-, simulation- and feedback-based training, with the mental-based training showing clear positive effects on participants. The studies analyzing the effects of stress on surgical performance showed both negative and positive effects on technical and non-technical performance.

CONCLUSIONS

The impact of stress responses presents an important factor in surgical environments, affecting residents' training and performance. This study identified the main methods used for monitoring stress parameters in surgical educational environments. The applied surgical stress management training methods were diverse and demonstrated positive effects on surgeons' stress levels and performance. There were negative and positive effects of stress on surgical performance, although a collective pattern on their effects was not clear.

Neuroenhancement of surgeons during robotic suturing

BACKGROUND

The initial phases of robotic surgical skills acquisition are associated with poor technical performance, such as low knot-tensile strength (KTS). Transcranial direct-current stimulation (tDCS) can improve force and accuracy in motor tasks but research in surgery is limited to open and laparoscopic tasks in students. More recently, robotic surgery has gained traction and is now the most common approach for certain procedures (e.g. prostatectomy). Early-phase robotic suturing performance is dependent on prefrontal cortex (PFC) activation, and this study aimed to determine whether performance can be improved with prefrontal tDCS.

METHODS

Fifteen surgical residents were randomized to either active then sham tDCS or sham then active tDCS, in two counterbalanced sessions in a double-blind crossover study. Within each session, participants performed a robotic suturing task repeated in three blocks: pre-, intra- and post-tDCS. During the intra-tDCS block, participants were randomized to either active tDCS (2 mA for 15 min) to the PFC or sham tDCS. Primary outcome measures of technical quality included KTS and error scores.

RESULTS

Significantly faster completion times were observed longitudinally, regardless of active (p < 0.001) or sham stimulation (p < 0.001). KTS was greater following active compared to sham stimulation (median: active = 44.35 N vs. sham = 27.12 N, p < 0.001). A significant reduction in error scores from "pre-" to "post-" (p = 0.029) were only observed in the active group.

CONCLUSION

tDCS could reduce error and enhance KTS during robotic suturing and warrants further exploration as an adjunct to robotic surgical training.

Methods and Measures for Mental Stress Assessment in Surgery: A Systematic Review of 20 Years of Literature

Real-time mental stress monitoring from surgeons and surgical staff in operating rooms may reduce surgical injuries, improve performance and quality of medical care, and accelerate implementation of stress-management strategies. Motivated by the increase in usage of objective and subjective metrics for cognitive monitoring and by the gap in reviews of experimental design setups and data analytics, a systematic review of 71 studies on mental stress and workload measurement in surgical settings, published in 2001-2020, is presented. Almost 61% of selected papers used both objective and subjective measures, followed by 25% that only administered subjective tools - mostly consisting of validated instruments and customized surveys. An overall increase in the total number of publications on intraoperative stress assessment was observed from mid-2010 s along with a momentum in the use of both subjective and real-time objective measures. Cardiac activity, including heart-rate variability metrics, stress hormones, and eye-tracking metrics were the most frequently and electroencephalography (EEG) was the least frequently used objective measures. Around 40% of selected papers collected at least two objective measures, 41% used wearable devices, 23% performed synchronization and annotation, and 76% conducted baseline or multi-point data acquisition. Furthermore, 93% used a variety of statistical techniques, 14% applied regression models, and only one study released a public, anonymized dataset. This review of data modalities, experimental setups, and analysis techniques for intraoperative stress monitoring highlights the initiatives of surgical data science and motivates research on computational techniques for mental and surgical skills assessment and cognition-guided surgery.

Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review

Surgical expertise does not have a clear definition and is often culturally associated with power, authority, prestige, and case number rather than more objective proxies of excellence. Multiple models of expertise progression have been proposed including the Dreyfus model, however, they all currently require subjective evaluation of skill. Recently, efforts have been made to improve the ways in which surgical excellence is measured and expertise is defined using artificial intelligence, video recordings, and accelerometers. However, these aforementioned methods of assessment are still subjective or indirect proxies of expertise, thus uncovering the neural mechanisms that differentiate expert surgeons from trainees may enhance the objectivity of surgical expertise validation. In fact, some researchers have already suggested that their neural imaging-based expertise classification methods outperform currently used methods of surgical skill certification such as the Fundamentals of Laparoscopic Surgery (FLS) scores. Such imaging biomarkers would not only help better identify the highest performing surgeons, but could also improve residency programs by providing more objective, evidence-based feedback and developmental milestones for those in training and perhaps act as a marker of surgical potential in medical students. Despite the potential advantages of using neural imaging in the assessment of surgical expertise, this field of research remains in its infancy. This systematic review identifies studies that have applied neuromonitoring in assessing surgical skill across levels of expertise. The goals of this review are to identify (1) the strongest neural indicators of surgical expertise, (2) the limitations of the current literature on this subject, (3) the most sensible future directions for further study. We found substantial evidence that surgical expertise can be delineated by differential activation and connectivity in the prefrontal cortex (PFC) across multiple task and neuroimaging modalities. Specifically, novices tend to have greater PFC activation than experts under standard conditions in bimanual and decision-making tasks. However, under high temporal demand tasks, experts had increased PFC activation whereas novices had decreased PFC activation. Common limitations uncovered in this review were that task difficulty was often insufficient to delineate between residents and attending. Moreover, attending level involvement was also low in multiple studies which may also have contributed to this issue. Most studies did not analyze the ability of their neuromonitoring findings to accurately classify subjects by level of expertise. Finally, the predominance of fNIRS as the neuromonitoring modality limits our ability to uncover the neural correlates of surgical expertise in non-cortical brain regions. Future studies should first strive to address these limitations. In the longer term, longitudinal within-subjects design over the course of a residency or even a career will also advance the field. Although logistically arduous, such studies would likely be most beneficial in demonstrating effects of increasing surgical expertise on regional brain activation and inter-region connectivity.

US Physicians' Perspective on the Sudden Shift to Telehealth: Survey Study

Background

Given the sudden shift to telemedicine during the early COVID-19 pandemic, we conducted a survey of practicing physicians’ experience with telehealth during the prepandemic and early pandemic periods. Our survey estimates that most patient visits in the United States during the early COVID-19 pandemic period were conducted via telehealth. Given this magnitude and the potential benefits and challenges of telehealth for the US health care system, in this paper, we obtain, summarize, and analyze telehealth views and experiences of US-based practicing-physicians.

Objective

The aim of this study was to examine the extent of shift toward telehealth training and care provision during the early pandemic from the US-based practicing physicians’ perspective. We also sought to determine the short- and long-term implications of this shift on the quality, access, and mode of US health care delivery.

Methods

We conducted a purposive, snowball-sampled survey of US practicing-physicians. A total of 148 physician completed the survey. Data were collected from July 17, 2020, through September 4, 2020.

Results

Sample training intensity scaled 21-fold during the early pandemic period, and patient-care visits conducted via telehealth increased, on average, from 13.1% directly before the pandemic to 59.7% during the early pandemic period. Surveyed physician respondents reported that telehealth patient visits and face-to-face patient visits are comparable in quality. The difference was not statistically significant based on a nonparametric sign test (P=.11). Moreover, physicians feel that telehealth care should continue to play a larger role (44.9% of total visits) in postpandemic health care in the United States. Our survey findings suggest a high market concentration in telehealth software, which is a market structural characteristic that may have implications on the cost and access of telehealth. The results varied markedly by physician employer type.

Conclusions

During the shift toward telehealth, there has been a considerable discovery among physicians regarding US telehealth physicians. Physicians are now better prepared to undertake telehealth care from a training perspective. They are favorable toward a permanently expanded telehealth role, with potential for enhanced health care access, and the realization of enhanced access may depend on market structural characteristics of telehealth software platforms.

High density optical neuroimaging predicts surgeons's subjective experience and skill levels

Measuring cognitive load is important for surgical education and patient safety. Traditional approaches of measuring cognitive load of surgeons utilise behavioural metrics to measure performance and surveys and questionnaires to collect reports of subjective experience. These have disadvantages such as sporadic data, occasionally intrusive methodologies, subjective or misleading self-reporting. In addition, traditional approaches use subjective metrics that cannot distinguish between skill levels. Functional neuroimaging data was collected using a high density, wireless NIRS device from sixteen surgeons (11 attending surgeons and 5 surgery resident) and 17 students while they performed two laparoscopic tasks (Peg transfer and String pass). Participant’s subjective mental load was assessed using the NASA-TLX survey. Machine learning approaches were used for predicting the subjective experience and skill levels. The Prefrontal cortex (PFC) activations were greater in students who reported higher-than-median task load, as measured by the NASA-TLX survey. However in the case of attending surgeons the opposite tendency was observed, namely higher activations in the lower v higher task loaded subjects. We found that response was greater in the left PFC of students particularly near the dorso- and ventrolateral areas. We quantified the ability of PFC activation to predict the differences in skill and task load using machine learning while focussing on the effects of NIRS channel separation distance on the results. Our results showed that the classification of skill level and subjective task load could be predicted based on PFC activation with an accuracy of nearly 90%. Our finding shows that there is sufficient information available in the optical signals to make accurate predictions about the surgeons’ subjective experiences and skill levels. The high accuracy of results is encouraging and suggest the integration of the strategy developed in this study as a promising approach to design automated, more accurate and objective evaluation methods.

The Role of the Prefrontal Cortex and Functional Connectivity during Maritime Operations: An fNIRS study

INTRODUCTION

Watchkeeping is a significant activity during maritime operations, and failures of sustained attention and decision-making can increase the likelihood of a collision.

METHODS

A study was conducted in a ship bridge simulator where 40 participants (20 experienced/20 inexperienced) performed: (1) a 20-min period of sustained attention to locate a target vessel and (2) a 10-min period of decision-making/action selection to perform an evasive maneuver. Half of the participants also performed an additional task of verbally reporting the position of their vessel. Activation of the prefrontal cortex (PFC) was captured via a 15-channel functional near-infrared spectroscopy (fNIRS) montage, and measures of functional connectivity were calculated frontal using graph-theoretic measures.

RESULTS

Neurovascular activation of right lateral area of the PFC decreased during sustained attention and increased during decision-making. The graph-theoretic analysis revealed that density declined during decision-making in comparison with the previous period of sustained attention, while local clustering declined during sustained attention and increased when participants prepared their evasive maneuver. A regression analysis revealed an association between network measures and behavioral outcomes, with respect to spotting the target vessel and making an evasive maneuver.

CONCLUSIONS

The right lateral area of the PFC is sensitive to watchkeeping and decision-making during operational performance. Graph-theoretic measures allow us to quantify patterns of functional connectivity and were predictive of safety-critical performance.

Sensors for Continuous Monitoring of Surgeon's Cognitive Workload in the Cardiac Operating Room

Monitoring healthcare providers’ cognitive workload during surgical procedures can provide insight into the dynamic changes of mental states that may affect patient clinical outcomes. The role of cognitive factors influencing both technical and non-technical skill are increasingly being recognized, especially as the opportunities to unobtrusively collect accurate and sensitive data are improving. Applying sensors to capture these data in a complex real-world setting such as the cardiac surgery operating room, however, is accompanied by myriad social, physical, and procedural constraints. The goal of this study was to investigate the feasibility of overcoming logistical barriers in order to effectively collect multi-modal psychophysiological inputs via heart rate (HR) and near-infrared spectroscopy (NIRS) acquisition in the real-world setting of the operating room. The surgeon was outfitted with HR and NIRS sensors during aortic valve surgery, and validation analysis was performed to detect the influence of intra-operative events on cardiovascular and prefrontal cortex changes. Signals collected were significantly correlated and noted intra-operative events and subjective self-reports coincided with observable correlations among cardiovascular and cerebral activity across surgical phases. The primary novelty and contribution of this work is in demonstrating the feasibility of collecting continuous sensor data from a surgical team member in a real-world setting.

Frontal theta brain activity varies as a function of surgical experience and task error

OBJECTIVE

Investigations into surgical expertise have almost exclusively focused on overt behavioral characteristics with little consideration of the underlying neural processes. Recent advances in neuroimaging technologies, for example, wireless, wearable scalp-recorded electroencephalography (EEG), allow an insight into the neural processes governing performance. We used scalp-recorded EEG to examine whether surgical expertise and task performance could be differentiated according to an oscillatory brain activity signal known as frontal theta-a putative biomarker for cognitive control processes.

DESIGN SETTING AND PARTICIPANTS

Behavioral and EEG data were acquired from dental surgery trainees with 1 year (n=25) and 4 years of experience (n=20) while they performed low and high difficulty drilling tasks on a virtual reality surgical simulator. EEG power in the 4-7 Hz range in frontal electrodes (indexing frontal theta) was examined as a function of experience, task difficulty and error rate.

RESULTS

Frontal theta power was greater for novices relative to experts (p=0.001), but did not vary according to task difficulty (p=0.15) and there was no Experience × Difficulty interaction (p=0.87). Brain-behavior correlations revealed a significant negative relationship between frontal theta and error in the experienced group for the difficult task (r=-0.594, p=0.0058), but no such relationship emerged for novices.

CONCLUSION

We find frontal theta power differentiates between surgical experiences but correlates only with error rates for experienced surgeons while performing difficult tasks. These results provide a novel perspective on the relationship between expertise and surgical performance.

Multitasking and Time Pressure in the Operating Room: Impact on Surgeons' Brain Function

OBJECTIVE

To assess the impact of multitasking and time pressure on surgeons' brain function during laparoscopic suturing.

SUMMARY BACKGROUND DATA

Recent neuroimaging evidence suggests that deterioration in surgical performance under time pressure is associated with deactivation of the prefrontal cortex (PFC), an area important for executive functions. However, the effect of multitasking on operator brain function remains unknown.

METHODS

Twenty-nine surgical residents performed an intracorporeal suturing task under four conditions: 1) self-paced suturing, 2) time-pressured suturing, 3) self-paced suturing plus decision-making, and 4) time-pressured suturing plus decision-making. Subjective workload was quantified using the Surgical Task Load Index. Technical skill was objectively assessed using task progression scores, error scores, leak volumes, and knot tensile strengths. PFC activation was measured using optical neuroimaging.

RESULTS

Compared with self-paced suturing, subjective workload (au) was significantly greater in time-pressured suturing (146.0 vs 196.0, P < 0.001), suturing with decision-making (146.0 vs 182.0, P < 0.001), and time-pressured suturing with decision-making (146.0 vs 227.0, P < 0.001). Technical performance during combined suturing and decision-making tasks was inferior to suturing alone under time pressure or self-paced conditions (P < 0.001). Significant dorsolateral PFC (DLPFC) activations were observed during self-paced suturing, and ventrolateral PFC (VLPFC) deactivations were identified during time-pressured suturing. However, suturing in conjunction with decision-making resulted in significant deactivation across both the VLPFC and DLPFC (P < 0.05). Random effects regression analysis confirmed decision-making predicts VLPFC and DLPFC deactivation (z = -2.62, P < 0.05).

CONCLUSIONS

Performance degradation during high workload conditions is associated with deactivation of prefrontal regions important for attentional control, working memory, and cognitive flexibility, particularly during tasks involving simultaneous motor and cognitive engagement.

Methodological Approaches and Recommendations for Functional Near-Infrared Spectroscopy Applications in HF/E Research

OBJECTIVE

The objective of this study was to systematically document current methods and protocols employed when using functional near-infrared spectroscopy (fNIRS) techniques in human factors and ergonomics (HF/E) research and generate recommendations for conducting and reporting fNIRS findings in HF/E applications.

METHOD

A total of 1,687 articles were identified through Ovid-MEDLINE, PubMed, Web of Science, and Scopus databases, of which 37 articles were included in the review based on review inclusion/exclusion criteria.

RESULTS

A majority of the HF/E fNIRS investigations were found in transportation, both ground and aviation, and in assessing cognitive (e.g., workload, working memory) over physical constructs. There were large variations pertaining to data cleaning, processing, and analysis approaches across the studies that warrant standardization of methodological approaches. The review identified major challenges in transparency and reporting of important fNIRS data collection and analyses specifications that diminishes study replicability, introduces potential biases, and increases likelihood of inaccurate results. As such, results reported in existing fNIRS studies need to be cautiously approached.

CONCLUSION

To improve the quality of fNIRS investigations and/or to facilitate its adoption and integration in different HF/E applications, such as occupational ergonomics and rehabilitation, recommendations for fNIRS data collection, processing, analysis, and reporting are provided.

Neuroenhancement in surgeons: benefits, risks and ethical dilemmas

Background

Surgeons traditionally aim to reduce mistakes in healthcare through repeated training and advancement of surgical technology. Recently, performance-enhancing interventions such as neurostimulation are emerging which may offset errors in surgical practice.

Methods

Use of transcranial direct-current stimulation (tDCS), a novel neuroenhancement technique that has been applied to surgeons to improve surgical technical performance, was reviewed. Evidence supporting tDCS improvements in motor and cognitive performance outside of the field of surgery was assessed and correlated with emerging research investigating tDCS in the surgical setting and potential applications to wider aspects of healthcare. Ethical considerations and future implications of using tDCS in surgical training and perioperatively are also discussed.

Results

Outside of surgery, tDCS studies demonstrate improved motor performance with regards to reaction time, task completion, strength and fatigue, while also suggesting enhanced cognitive function through multitasking, vigilance and attention assessments. In surgery, current research has demonstrated improved performance in open knot-tying, laparoscopic and robotic skills while also offsetting subjective temporal demands. However, a number of ethical issues arise from the potential application of tDCS in surgery in the form of safety, coercion, distributive justice and fairness, all of which must be considered prior to implementation.

Conclusion

Neuroenhancement may improve motor and cognitive skills in healthcare professions with impact on patient safety. Implementation will require accurate protocols and regulations to balance benefits with the associated ethical dilemmas, and to direct safe use for clinicians and patients.

A Neuroergonomics Approach to Mental Workload, Engagement and Human Performance

The assessment and prediction of cognitive performance is a key issue for any discipline concerned with human operators in the context of safety-critical behavior. Most of the research has focused on the measurement of mental workload but this construct remains difficult to operationalize despite decades of research on the topic. Recent advances in Neuroergonomics have expanded our understanding of neurocognitive processes across different operational domains. We provide a framework to disentangle those neural mechanisms that underpin the relationship between task demand, arousal, mental workload and human performance. This approach advocates targeting those specific mental states that precede a reduction of performance efficacy. A number of undesirable neurocognitive states (mind wandering, effort withdrawal, perseveration, inattentional phenomena) are identified and mapped within a two-dimensional conceptual space encompassing task engagement and arousal. We argue that monitoring the prefrontal cortex and its deactivation can index a generic shift from a nominal operational state to an impaired one where performance is likely to degrade. Neurophysiological, physiological and behavioral markers that specifically account for these states are identified. We then propose a typology of neuroadaptive countermeasures to mitigate these undesirable mental states.

Using fMRI to investigate the potential cause of inverse oxygenation reported in fNIRS studies of motor imagery

Motor imagery (MI) is a commonly used cognitive task in brain-computer interface (BCI) applications because it produces reliable activity in motor-planning regions. However, a number of functional near-infrared spectroscopy (fNIRS) studies have reported the unexpected finding of inverse oxygenation: increased deoxyhemoglobin and decreased oxyhemoglobin during task periods. This finding questions the reliability of fNIRS for BCI applications given that MI activation should result in a focal increase in blood oxygenation. In an attempt to elucidate this phenomenon, fMRI and fNIRS data were acquired on 15 healthy participants performing a MI task. The fMRI data provided global coverage of brain activity, thus allowing visualization of all potential brain regions activated and deactivated during task periods. Indeed, fMRI results from seven subjects included activation in the primary motor cortex and/or the pre-supplementary motor area during the rest periods in addition to the expected activation in the supplementary motor and premotor areas. Of these seven subjects, two showed inverse oxygenation with fNIRS. The proximity of the regions showing inverse oxygenation to the motor planning regions suggests that inverse activation detected by fNIRS may likely be a consequence of partial volume errors due to the sensitivity of the optodes to both primary motor and motor planning regions.

Towards a Multimodal Model of Cognitive Workload Through Synchronous Optical Brain Imaging and Eye Tracking Measures

Recent advances in neuroimaging technologies have rendered multimodal analysis of operators’ cognitive processes in complex task settings and environments increasingly more practical. In this exploratory study, we utilized optical brain imaging and mobile eye tracking technologies to investigate the behavioral and neurophysiological differences among expert and novice operators while they operated a human-machine interface in normal and adverse conditions. In congruence with related work, we observed that experts tended to have lower prefrontal oxygenation and exhibit gaze patterns that are better aligned with the optimal task sequence with shorter fixation durations as compared to novices. These trends reached statistical significance only in the adverse condition where the operators were prompted with an unexpected error message. Comparisons between hemodynamic and gaze measures before and after the error message indicated that experts’ neurophysiological response to the error involved a systematic increase in bilateral dorsolateral prefrontal cortex (dlPFC) activity accompanied with an increase in fixation durations, which suggests a shift in their attentional state, possibly from routine process execution to problem detection and resolution. The novices’ response was not as strong as that of experts, including a slight increase only in the left dlPFC with a decreasing trend in fixation durations, which is indicative of visual search behavior for possible cues to make sense of the unanticipated situation. A linear discriminant analysis model capitalizing on the covariance structure among hemodynamic and eye movement measures could distinguish experts from novices with 91% accuracy. Despite the small sample size, the performance of the linear discriminant analysis combining eye fixation and dorsolateral oxygenation measures before and after an unexpected event suggests that multimodal approaches may be fruitful for distinguishing novice and expert performance in similar neuroergonomic applications in the field.

Association of Residents' Neural Signatures With Stress Resilience During Surgery

Importance

Intraoperative stressors may compound cognitive load, prompting performance decline and threatening patient safety. However, not all surgeons cope equally well with stress, and the disparity between performance stability and decline under high cognitive demand may be characterized by differences in activation within brain areas associated with attention and concentration such as the prefrontal cortex (PFC).

Objective

To compare PFC activation between surgeons demonstrating stable performance under temporal stress with those exhibiting stress-related performance decline.

Design, Setting, and Participants

Cohort study conducted from July 2015 to September 2016 at the Imperial College Healthcare National Health Service Trust, England. One hundred two surgical residents (postgraduate year 1 and greater) were invited to participate, of which 33 agreed to partake.

Exposures

Participants performed a laparoscopic suturing task under 2 conditions: self-paced (SP; without time-per-knot restrictions), and time pressure (TP; 2-minute per knot time restriction).

Main Outcomes and Measures

A composite deterioration score was computed based on between-condition differences in task performance metrics (task progression score [arbitrary units], error score [millimeters], leak volume [milliliters], and knot tensile strength [newtons]). Based on the composite score, quartiles were computed reflecting performance stability (quartile 1 [Q1]) and decline (quartile 4 [Q4]). Changes in PFC oxygenated hemoglobin concentration (HbO2) measured at 24 different locations using functional near-infrared spectroscopy were compared between Q1 and Q4. Secondary outcomes included subjective workload (Surgical Task Load Index) and heart rate.

Results

Of the 33 participants, the median age was 33 years, the range was 29 to 56 years, and 27 were men (82%). The Q1 residents demonstrated task-induced increases in HbO2 across the bilateral ventrolateral PFC (VLPFC) and right dorsolateral PFC in the SP condition and in the VLPFC in the TP condition. In contrast, Q4 residents demonstrated decreases in HbO2 in both conditions. The magnitude of PFC activation (change in HbO2) was significantly greater in Q1 than Q4 across the bilateral VLPFC during both SP (mean [SD] left VLPFC: Q1, 0.44 [1.30] μM; Q4, -0.21 [2.05] μM; P < .001; right VLPFC: Q1, 0.46 [1.12] μM; Q4, -0.15 [2.14] μM; P < .001) and TP (mean [SD] left VLPFC: Q1, 0.44 [1.36] μM; Q4, -0.03 [1.83] μM; P = .001; right VLPFC: Q1, 0.49 [1.70] μM; Q4, -0.32 [2.00] μM; P < .001) conditions. There were no significant between-group differences in Surgical Task Load Index or heart rate in either condition.

Conclusions and Relevance

Performance stability within TP is associated with sustained prefrontal activation indicative of preserved attention and concentration, whereas performance decline is associated with prefrontal deactivation that may represent task disengagement.

From Emotions to Mood Disorders: A Survey on Gait Analysis Methodology

Mood disorders affect more than 300 million people worldwide and can cause devastating consequences. Elderly people and patients with neurological conditions are particularly susceptible to depression. Gait and body movements can be affected by mood disorders, and thus they can be used as a surrogate sign, as well as an objective index for pervasive monitoring of emotion and mood disorders in daily life. Here we review evidence that demonstrates the relationship between gait, emotions and mood disorders, highlighting the potential of a multimodal approach that couples gait data with physiological signals and home-based monitoring for early detection and management of mood disorders. This could enhance self-awareness, enable the development of objective biomarkers that identify high risk subjects and promote subject-specific treatment.

Neural Efficiency of Human-Robotic Feedback Modalities Under Stress Differs With Gender

Sensory feedback, which can be presented in different modalities - single and combined, aids task performance in human-robotic interaction (HRI). However, combining feedback modalities does not always lead to optimal performance. Indeed, it is not known how feedback modalities affect operator performance under stress. Furthermore, there is limited information on how feedback affects neural processes differently for males and females and under stress. This is a critical gap in the literature, particularly in the domain of surgical robotics, where surgeons are under challenging socio-technical environments that burden them physiologically. In the present study, we posited operator performance as the summation of task performance and neurophysiological cost of maintaining that performance. In a within-subject design, we used functional near-infrared spectroscopy to assess cerebral activations of 12 participants who underwent a 3D manipulation task within a virtual environment with concurrent feedback (visual and visual + haptic) in the presence and absence of a cognitive stressor. Cognitive stress was induced with the serial-7 subtraction test. We found that while task performance was higher with visual than visual + haptic feedback, it degraded under stress. The two feedback modalities were found to be associated with varying neural activities and neural efficiencies, and these were stress- and gender-dependent. Our findings engender further investigation into effectiveness of feedback modalities on males and females under stressful conditions in HRI.

Robotic Surgery Improves Technical Performance and Enhances Prefrontal Activation During High Temporal Demand

Robotic surgery may improve technical performance and reduce mental demands compared to laparoscopic surgery. However, no studies have directly compared the impact of robotic and laparoscopic techniques on surgeons' brain function. This study aimed to assess the effect of the operative platform (robotic surgery or conventional laparoscopy) on prefrontal cortical activation during a suturing task performed under temporal demand. Eight surgeons (mean age ± SD = 34.5 ± 2.9 years, male:female ratio = 7:1) performed an intracorporeal suturing task in a self-paced manner and under a 2 min time restriction using conventional laparoscopic and robotic techniques. Prefrontal activation was assessed using near-infrared spectroscopy, subjective workload was captured using SURG-TLX questionnaires, and a continuous heart rate monitor measured systemic stress responses. Task progression scores (au), error scores (au), leak volumes (mL) and knot tensile strengths (N) provided objective assessment of technical performance. Under time pressure, robotic suturing led to improved technical performance (median task progression score: laparoscopic suturing = 4.5 vs. robotic suturing = 5.0; z = - 2.107, p = 0.035; median error score: laparoscopic suturing = 3.0 mm vs. robotic suturing = 2.1 mm; z = - 2.488, p = 0.013). Compared to laparoscopic suturing, greater prefrontal activation was identified in seven channels located primarily in lateral prefrontal regions. These results suggest that robotic surgery improves performance during high workload conditions and is associated with enhanced activation in regions of attention, concentration and task engagement.

Evaluation of a pneumatic surgical robot with dynamic force feedback

Robot-assisted surgery is limited by the lack of haptic feedback and increased operating times. Force scaling adjusts feedback transmitted to the operator through the use of scaling factors. Herein, we investigate how force scaling affects forces exerted in robotic surgery during simple and complex tasks, using a pneumatic surgical robot, IBIS VI. Secondary objectives were to test the effects of force scaling on operating time, depth of needle insertion and user satisfaction. Two novice males performed simple (modified block transfer) and complex (needle insertion) tasks under four scaling factors: 0.0, 0.5, 1.0 and 2.0. Single-blind experiments were repeated five times, with alternating scaling factors in random order. Increasing the scaling factor from 0.0 to 2.0 reduces forces in block transfer (p = 0.04). All feedback conditions reduce forces in needle insertion compared to baseline (0.5: p < 0.001, 1.0: p = 0.001, 2.0: p = 0.001). Time to complete block transfer is shorter for scaling factor 0.5 (p = 0.02), but not for 1.0 (p = 0.05) or 2.0 (p = 0.48), compared to baseline. Depth of needle insertion decreases consistently with incremental scaling factors (p < 0.001). Further reductions are observed upon augmenting feedback (0.5-2.0: p = 0.02). User satisfaction in block transfer is highest for intermediate scaling factors (0.0-1.0: p = 0.01), but no change is observed in needle insertion (p = 0.99). Increments in scaling factor reduce forces exerted, particularly in tasks requiring precision. Depth of needle insertion follows a similar pattern, but operating time and user satisfaction are improved by intermediate scaling factors. In summary, dynamic adjustment of force feedback can improve operative outcomes and advance surgical automation.

Systematic review of measurement tools to assess surgeons' intraoperative cognitive workload

BACKGROUND

Surgeons in the operating theatre deal constantly with high-demand tasks that require simultaneous processing of a large amount of information. In certain situations, high cognitive load occurs, which may impact negatively on a surgeon's performance. This systematic review aims to provide a comprehensive understanding of the different methods used to assess surgeons' cognitive load, and a critique of the reliability and validity of current assessment metrics.

METHODS

A search strategy encompassing MEDLINE, Embase, Web of Science, PsycINFO, ACM Digital Library, IEEE Xplore, PROSPERO and the Cochrane database was developed to identify peer-reviewed articles published from inception to November 2016. Quality was assessed by using the Medical Education Research Study Quality Instrument (MERSQI). A summary table was created to describe study design, setting, specialty, participants, cognitive load measures and MERSQI score.

RESULTS

Of 391 articles retrieved, 84 met the inclusion criteria, totalling 2053 unique participants. Most studies were carried out in a simulated setting (59 studies, 70 per cent). Sixty studies (71 per cent) used self-reporting methods, of which the NASA Task Load Index (NASA-TLX) was the most commonly applied tool (44 studies, 52 per cent). Heart rate variability analysis was the most used real-time method (11 studies, 13 per cent).

CONCLUSION

Self-report instruments are valuable when the aim is to assess the overall cognitive load in different surgical procedures and assess learning curves within competence-based surgical education. When the aim is to assess cognitive load related to specific operative stages, real-time tools should be used, as they allow capture of cognitive load fluctuation. A combination of both subjective and objective methods might provide optimal measurement of surgeons' cognition.