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Introzzi L, Zonca J, Cabitza F, Cherubini P, Reverberi C. Enhancing human-AI collaboration: The case of colonoscopy. Dig Liver Dis 2024; 56:1131-1139. [PMID: 37940501 DOI: 10.1016/j.dld.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023]
Abstract
Diagnostic errors impact patient health and healthcare costs. Artificial Intelligence (AI) shows promise in mitigating this burden by supporting Medical Doctors in decision-making. However, the mere display of excellent or even superhuman performance by AI in specific tasks does not guarantee a positive impact on medical practice. Effective AI assistance should target the primary causes of human errors and foster effective collaborative decision-making with human experts who remain the ultimate decision-makers. In this narrative review, we apply these principles to the specific scenario of AI assistance during colonoscopy. By unraveling the neurocognitive foundations of the colonoscopy procedure, we identify multiple bottlenecks in perception, attention, and decision-making that contribute to diagnostic errors, shedding light on potential interventions to mitigate them. Furthermore, we explored how existing AI devices fare in clinical practice and whether they achieved an optimal integration with the human decision-maker. We argue that to foster optimal Human-AI collaboration, future research should expand our knowledge of factors influencing AI's impact, establish evidence-based cognitive models, and develop training programs based on them. These efforts will enhance human-AI collaboration, ultimately improving diagnostic accuracy and patient outcomes. The principles illuminated in this review hold more general value, extending their relevance to a wide array of medical procedures and beyond.
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Affiliation(s)
- Luca Introzzi
- Department of Psychology, Università Milano - Bicocca, Milano, Italy
| | - Joshua Zonca
- Department of Psychology, Università Milano - Bicocca, Milano, Italy; Milan Center for Neuroscience, Università Milano - Bicocca, Milano, Italy
| | - Federico Cabitza
- Department of Informatics, Systems and Communication, Università Milano - Bicocca, Milano, Italy; IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
| | - Paolo Cherubini
- Department of Brain and Behavioral Sciences, Università Statale di Pavia, Pavia, Italy
| | - Carlo Reverberi
- Department of Psychology, Università Milano - Bicocca, Milano, Italy; Milan Center for Neuroscience, Università Milano - Bicocca, Milano, Italy.
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Satterwhite S, Nguyen MLT, Honcharov V, McDermott AM, Sarkar U. "Good Care Is Slow Enough to Be Able to Pay Attention": Primary Care Time Scarcity and Patient Safety. J Gen Intern Med 2024; 39:1575-1582. [PMID: 38360962 PMCID: PMC11255151 DOI: 10.1007/s11606-024-08658-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/24/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND There is growing, widespread recognition that expectations of US primary care vastly exceed the time and resources allocated to it. Little research has directly examined how time scarcity contributes to harm or patient safety incidents not readily capturable by population-based quality metrics. OBJECTIVE To examine near-miss events identified by primary care physicians in which taking additional time improved patient care or prevented harm. DESIGN Qualitative study based on semi-structured interviews. PARTICIPANTS Twenty-five primary care physicians practicing in the USA. APPROACH Participants completed a survey that included demographic questions, the Ballard Organizational Temporality Scale and the Mini-Z scale, followed by a one hour qualitative interview over video-conference (Zoom). Iterative thematic qualitative data analysis was conducted. KEY RESULTS Primary care physicians identified several types of near-miss events in which taking extra time during visits changed their clinical management. These were evident in five types of patient care episodes: high-risk social situations, high-risk medication regimens requiring patient education, high acuity conditions requiring immediate workup or treatment, interactions of physical and mental health, and investigating more subtle clinical suspicions. These near-miss events highlight the ways in which unreasonably large patient panels and packed schedules impede adequate responses to patient care episodes that are time sensitive and intensive or require flexibility. CONCLUSIONS Primary care physicians identify and address patient safety issues and high-risk situations by spending more time than allotted for a given patient encounter. Current quality metrics do not account for this critical aspect of primary care work. Current healthcare policy and organization create time scarcity. Interventions to address time scarcity and to measure its prevalence and implications for care quality and safety are urgently needed.
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Affiliation(s)
- Shannon Satterwhite
- Department of Family and Community Medicine, UC Davis Health, Sacramento, CA, USA
| | - Michelle-Linh T Nguyen
- Division of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
- Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Vlad Honcharov
- Division of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
- Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Aoife M McDermott
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
- Aston University, Birmingham, UK
| | - Urmimala Sarkar
- Division of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
- UCSF Pride Hall, San Francisco, CA, USA.
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Andersen AG, Riparbelli AC, Siebner HR, Konge L, Bjerrum F. Using neuroimaging to assess brain activity and areas associated with surgical skills: a systematic review. Surg Endosc 2024; 38:3004-3026. [PMID: 38653901 DOI: 10.1007/s00464-024-10830-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/24/2024] [Indexed: 04/25/2024]
Abstract
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.
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Affiliation(s)
- Annarita Ghosh Andersen
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark.
- Department of Cardiothoracic Surgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Agnes Cordelia Riparbelli
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark
| | - Hartwig Roman Siebner
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
- Department of Neurology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bjerrum
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Gastrounit, Surgical Section, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
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Howie EE, Ambler O, Gunn EG, Dias RD, Wigmore SJ, Skipworth RJ, Yule SJ. Surgical Sabermetrics: A Scoping Review of Technology-enhanced Assessment of Nontechnical Skills in the Operating Room. Ann Surg 2024; 279:973-984. [PMID: 38258573 PMCID: PMC11086675 DOI: 10.1097/sla.0000000000006211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
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.
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Affiliation(s)
- Emma E. Howie
- Clinical Surgery, University of Edinburgh & Royal Infirmary of Edinburgh, Edinburgh, Scotland
- Edinburgh Surgical Sabermetrics Group, University of Edinburgh, Edinburgh, Scotland
| | - Olivia Ambler
- Edinburgh Surgical Sabermetrics Group, University of Edinburgh, Edinburgh, Scotland
| | - Eilidh G.M. Gunn
- Clinical Surgery, University of Edinburgh & Royal Infirmary of Edinburgh, Edinburgh, Scotland
- Edinburgh Surgical Sabermetrics Group, University of Edinburgh, Edinburgh, Scotland
| | - Roger D. Dias
- Edinburgh Surgical Sabermetrics Group, University of Edinburgh, Edinburgh, Scotland
- Human Factors and Cognitive Engineering Lab, STRATUS Centre for Medical Simulation, Brigham & Women’s Hospital, Boston, MA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Stephen J. Wigmore
- Clinical Surgery, University of Edinburgh & Royal Infirmary of Edinburgh, Edinburgh, Scotland
- Edinburgh Surgical Sabermetrics Group, University of Edinburgh, Edinburgh, Scotland
| | - Richard J.E. Skipworth
- Clinical Surgery, University of Edinburgh & Royal Infirmary of Edinburgh, Edinburgh, Scotland
- Edinburgh Surgical Sabermetrics Group, University of Edinburgh, Edinburgh, Scotland
| | - Steven J. Yule
- Clinical Surgery, University of Edinburgh & Royal Infirmary of Edinburgh, Edinburgh, Scotland
- Edinburgh Surgical Sabermetrics Group, University of Edinburgh, Edinburgh, Scotland
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Tjønnås MS, Muller S, Våpenstad C, Tjønnås J, Ose SO, Das A, Sandsund M. Stress responses in surgical trainees during simulation-based training courses in laparoscopy. BMC MEDICAL EDUCATION 2024; 24:407. [PMID: 38610013 PMCID: PMC11010405 DOI: 10.1186/s12909-024-05393-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Simulation-based training courses in laparoscopy have become a fundamental part of surgical training programs. Surgical skills in laparoscopy are challenging to master, and training in these skills induces stress responses in trainees. There is limited data on trainees' stress levels, the stress responses related to training on different laparoscopic simulators, and how previous experiences influence trainees' stress response during a course. This study investigates physiologic, endocrine and self-reported stress responses during simulation-based surgical skills training in a course setting. METHODS We conducted a prospective observational study of trainees attending basic laparoscopic skills training courses at a national training centre. During the three-day course, participants trained on different laparoscopic simulators: Two box-trainers (the D-box and P.O.P. trainer) and a virtual reality simulator (LAPMentor™). Participants' stress responses were examined through heart rate variability (HRV), saliva cortisol, and the State Trait Anxiety Inventory-6 (STAI-6). The correlation between previous laparoscopic experiences and stress response measurements was explored. RESULTS Twenty-four surgical trainees were included in the study. Compared to resting conditions, stress measures were significantly higher during simulation-training activity (the D-box (SDNN = 58.5 ± 23.4; LF/HF-ratio = 4.58 ± 2.71; STAI-6 = 12.3 ± 3.9, P < 0.05), the P.O.P trainer (SDNN = 55.7 ± 7.4; RMSSD = 32.4 ± 17.1; STAI-6 = 12.1 ± 3.9, P < 0.05), and the LAPMentor™ (SDNN = 59.1 ± 18.5; RMSSD = 34.3 ± 19.7; LF/HF-ratio = 4.71 ± 2.64; STAI-6 = 9.9 ± 3.0, P < 0.05)). A significant difference in endocrine stress response was seen for the simulation-training activity on the D-box (saliva cortisol: 3.48 ± 1.92, P < 0.05), however, no significant differences were observed between the three simulators. A moderate correlation between surgical experience, and physiologic and endocrine stress response was observed (RMSSD: r=-0.31; SDNN: r=-0.42; SD2/SD1 ratio: r = 0.29; Saliva cortisol: r = 0.46; P < 0.05), and a negative moderate correlation to self-reported stress (r=-0.42, P < 0.05). CONCLUSION Trainees have a significant higher stress response during simulation-training compared to resting conditions, with no difference in stress response between the simulators. Significantly higher cortisol levels were observed on the D-box, indicating that simulation tasks with time pressure stress participants the most. Trainees with more surgical experience are associated with higher physiologic stress measures, but lower self-reported stress scores, demonstrating that surgical experience influences trainees' stress response during simulation-based skills training courses.
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Affiliation(s)
- Maria Suong Tjønnås
- Department of Neuromedicine and Movement Science (INB), Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, N-7491, Norway.
- Department of Health Research, SINTEF Digital, SINTEF, P.O. Box 4760, Torgarden, Trondheim, NO-7465, Norway.
| | - Sébastien Muller
- Department of Health Research, SINTEF Digital, SINTEF, P.O. Box 4760, Torgarden, Trondheim, NO-7465, Norway
| | - Cecilie Våpenstad
- Department of Health Research, SINTEF Digital, SINTEF, P.O. Box 4760, Torgarden, Trondheim, NO-7465, Norway
- Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, N-7491, Norway
- The National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy (MiDT), St. Olavs Hospital, Trondheim University Hospital, P.O. Box 3250, Prinsesse Kristinas Gate 5, Torgarden, Trondheim, NO-7006, Norway
| | - Johannes Tjønnås
- Department of Mathematics and Cybernetics, SINTEF Digital, SINTEF, P.O. Box 4760, Torgarden, Trondheim, NO- 7465, Norway
| | - Solveig Osborg Ose
- Department of Health Research, SINTEF Digital, SINTEF, P.O. Box 4760, Torgarden, Trondheim, NO-7465, Norway
| | - Anita Das
- Department of Neuromedicine and Movement Science (INB), Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, N-7491, Norway
| | - Mariann Sandsund
- Department of Health Research, SINTEF Digital, SINTEF, P.O. Box 4760, Torgarden, Trondheim, NO-7465, Norway
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Letvak S, Apple B, Jenkins M. Factors Affecting Perioperative Nurse Adherence to Ergonomic Safety Measures. AORN J 2024; 119:210-221. [PMID: 38407344 DOI: 10.1002/aorn.14097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 09/06/2023] [Accepted: 09/06/2023] [Indexed: 02/27/2024]
Abstract
AORN has identified safety risks unique to the perioperative setting and has developed ergonomic safety measures to help prevent musculoskeletal injuries and disorders. Little is known about adherence to these safety measures or the perceived barriers and facilitators to adherence. This study used a cross-sectional survey to determine the prevalence of pain and occurrence of musculoskeletal injuries and disorders. We asked perioperative staff members about their perceived barriers and facilitators to adherence with safety measures. A total of 155 perioperative nurses in one health system completed the online survey (55% response rate). Most (93%) had experienced at least one musculoskeletal injury or disorder or related pain. Years worked as a perioperative nurse and having neck pain were associated with safety measure adherence. The most reported barrier to safety measure adherence was inadequate staffing. Study findings highlight the need for increased attention to the physical workload demands in the perioperative setting.
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Liu J, Zou X, Gu J, Yu Q, Dong Z, Zuo H, Chen X, Du X, Zou D, Han Y, Peng J, Cheng O. Altered connectivity in the cognitive control-related prefrontal cortex in Parkinson's disease with rapid eye movement sleep behavior disorder. Brain Imaging Behav 2023; 17:702-714. [PMID: 37721659 DOI: 10.1007/s11682-023-00796-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 09/19/2023]
Abstract
Rapid eye movement sleep behavior disorder (RBD) frequently occurs in Parkinson's disease (PD), however, the exact pathophysiological mechanism is not clear. The prefrontal cortex (PFC), especially ventrolateral prefrontal cortex (VLPFC), dorsolateral prefrontal cortex (DLPFC), and inferior frontal gyrus (IFG) which may play roles by regulating cognitive control processes. The purpose of this study was to investigate whether there is abnormal functional connectivity (FC) maps and volume changes in PD with RBD(PD-RBD). We recruited 20 PD-RBD, 20 PD without RBD (PD-nRBD), and 20 normal controls (NC). We utilized resting-state functional Magnetic Resonance Imaging (rs-MRI) to explore FC changes based on regions of interest (VLPFC, DLPFC, and IFG), and used voxel-based morphology technology to analyze whole-brain volumes by 3D-T1 structural MRI. Except the REM sleep behavioral disorders questionnaire (RBDSQ), the PD-RBD showed lower visuospatial/executive and attention scores than the NC group. The RBDSQ scores were significantly positively correlated with zFC of right DLPFC to bilateral posterior cingulate cortex (PCC) (P = 0.0362, R = 0.4708, AlphaSim corrected) and also significantly positively correlated with zFC of left VLPFC to right inferior temporal (P = 0.0157, R = 0.5323, AlphaSim corrected) in PD-RBD group. Furthermore, abnormal correlations with zFC values were also found in some cognitive subdomains in PD-RBD group. The study may suggest that in PD-RBD patients, the presence of RBD may be related to the abnormal FC of VLPFC and DLPFC, meanwhile, the abnormal FC of DLPFC and IFG may be related to the mechanisms of cognitive impairment.
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Affiliation(s)
- Jinjing Liu
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
- Department of Rehabilitation Medicine, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Xiaoya Zou
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Jinming Gu
- Department of Radiology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Qian Yu
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Zhaoying Dong
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Hongzhou Zuo
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Xiaocui Chen
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Xinyi Du
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Dezhi Zou
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Yu Han
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Juan Peng
- Department of Radiology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China.
| | - Oumei Cheng
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China.
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Paquette S, Kilcullen M, Hoffman O, Hernandez J, Mehta A, Salas E, Greilich PE. Handoffs and the challenges to implementing teamwork training in the perioperative environment. Front Psychol 2023; 14:1187262. [PMID: 37397334 PMCID: PMC10310998 DOI: 10.3389/fpsyg.2023.1187262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/16/2023] [Indexed: 07/04/2023] Open
Abstract
Perioperative handoffs are high-risk events for miscommunications and poor care coordination, which cause patient harm. Extensive research and several interventions have sought to overcome the challenges to perioperative handoff quality and safety, but few efforts have focused on teamwork training. Evidence shows that team training decreases surgical morbidity and mortality, and there remains a significant opportunity to implement teamwork training in the perioperative environment. Current perioperative handoff interventions face significant difficulty with adherence which raises concerns about the sustainability of their impact. In this perspective article, we explain why teamwork is critical to safe and reliable perioperative handoffs and discuss implementation challenges to the five core components of teamwork training programs in the perioperative environment. We outline evidence-based best practices imperative for training success and acknowledge the obstacles to implementing those best practices. Explicitly identifying and discussing these obstacles is critical to designing and implementing teamwork training programs fit for the perioperative environment. Teamwork training will equip providers with the foundational teamwork competencies needed to effectively participate in handoffs and utilize handoff interventions. This will improve team effectiveness, adherence to current perioperative handoff interventions, and ultimately, patient safety.
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Affiliation(s)
- Shannon Paquette
- Office of Undergraduate Medical Education, UT Southwestern Medical Center, Dallas, TX, United States
| | - Molly Kilcullen
- Department of Psychological Sciences, Rice University, Houston, TX, United States
| | - Olivia Hoffman
- Division of Critical Care Medicine, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States
| | - Jessica Hernandez
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Ankeeta Mehta
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, United States
| | - Eduardo Salas
- Department of Psychological Sciences, Rice University, Houston, TX, United States
| | - Philip E. Greilich
- Department of Anesthesiology and Pain Management, Health System Chief Quality Office, Office of Undergraduate Medical Education, UT Southwestern Medical Center, Dallas, TX, United States
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Souchet AD, Lourdeaux D, Burkhardt JM, Hancock PA. Design guidelines for limiting and eliminating virtual reality-induced symptoms and effects at work: a comprehensive, factor-oriented review. Front Psychol 2023; 14:1161932. [PMID: 37359863 PMCID: PMC10288216 DOI: 10.3389/fpsyg.2023.1161932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/16/2023] [Indexed: 06/28/2023] Open
Abstract
Virtual reality (VR) can induce side effects known as virtual reality-induced symptoms and effects (VRISE). To address this concern, we identify a literature-based listing of these factors thought to influence VRISE with a focus on office work use. Using those, we recommend guidelines for VRISE amelioration intended for virtual environment creators and users. We identify five VRISE risks, focusing on short-term symptoms with their short-term effects. Three overall factor categories are considered: individual, hardware, and software. Over 90 factors may influence VRISE frequency and severity. We identify guidelines for each factor to help reduce VR side effects. To better reflect our confidence in those guidelines, we graded each with a level of evidence rating. Common factors occasionally influence different forms of VRISE. This can lead to confusion in the literature. General guidelines for using VR at work involve worker adaptation, such as limiting immersion times to between 20 and 30 min. These regimens involve taking regular breaks. Extra care is required for workers with special needs, neurodiversity, and gerontechnological concerns. In addition to following our guidelines, stakeholders should be aware that current head-mounted displays and virtual environments can continue to induce VRISE. While no single existing method fully alleviates VRISE, workers' health and safety must be monitored and safeguarded when VR is used at work.
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Affiliation(s)
- Alexis D. Souchet
- Heudiasyc UMR 7253, Alliance Sorbonne Université, Université de Technologie de Compiègne, CNRS, Compiègne, France
- Institute for Creative Technologies, University of Southern California, Los Angeles, CA, United States
| | - Domitile Lourdeaux
- Heudiasyc UMR 7253, Alliance Sorbonne Université, Université de Technologie de Compiègne, CNRS, Compiègne, France
| | | | - Peter A. Hancock
- Department of Psychology, University of Central Florida, Orlando, FL, United States
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Goble M, Caddick V, Patel R, Modi H, Darzi A, Orihuela-Espina F, Leff DR. Optical neuroimaging and neurostimulation in surgical training and assessment: A state-of-the-art review. FRONTIERS IN NEUROERGONOMICS 2023; 4:1142182. [PMID: 38234498 PMCID: PMC10790870 DOI: 10.3389/fnrgo.2023.1142182] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/03/2023] [Indexed: 01/19/2024]
Abstract
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.
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Affiliation(s)
- Mary Goble
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Tokuno J, Carver TE, Fried GM. Measurement and Management of Cognitive Load in Surgical Education: A Narrative Review. JOURNAL OF SURGICAL EDUCATION 2023; 80:208-215. [PMID: 36335034 DOI: 10.1016/j.jsurg.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/18/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Cognitive load should be considered in designing optimal educational programs in health care. Despite the highly demanding nature of surgery and surgical education, a consensus on how to manage cognitive load has not been established. The objective of this review is to map out how recent surgical education research incorporates cognitive load. METHODS A literature search was performed using keywords related to cognitive load and digital education up to December 2021. Studies published in English relevant to assessment and management of cognitive load in surgical education were included. Terminology, assessment tools, association with different surgical procedures and training modalities, and programs considering cognitive load were reported. RESULTS We identified several terms to describe cognitive load. Cognitive load was measured by subjective, self-reported questionnaires and by objective measurements, such as physiological parameters or estimated by reaction time to secondary tasks. Subjective measurements reported cognitive load in one or multiple dimensions. Correlations between subjective and objective measurements were shown in multiple studies. Overall, higher cognitive load was observed in training for more complex tasks and high-fidelity modalities, and among less experienced trainees. Cognitive load theory has been lately incorporated into designing teaching programs. CONCLUSIONS A broad range of terms and assessment tools were identified for cognitive load. To maximize the learning outcome, management of cognitive load is necessary in surgical education. This review summarizes the current knowledge in assessment and management of cognitive load in surgical education and provides suggestions for future studies.
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Affiliation(s)
- Junko Tokuno
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada; Steinberg Centre for Simulation and Interactive Learning, Faculty of Medicine and Health Science, Montreal, Quebec, Canada
| | - Tamara E Carver
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada; Steinberg Centre for Simulation and Interactive Learning, Faculty of Medicine and Health Science, Montreal, Quebec, Canada; Department of Surgery, McGill University, Montreal, Quebec, Canada; Institute for Health Sciences Education, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Gerald M Fried
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada; Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada; Department of Surgery, McGill University, Montreal, Quebec, Canada; Institute for Health Sciences Education, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada.
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Armstrong BA, Nemrodov D, Tung A, Graham SJ, Grantcharov T. Electroencephalography can provide advance warning of technical errors during laparoscopic surgery. Surg Endosc 2022; 37:2817-2825. [PMID: 36478137 DOI: 10.1007/s00464-022-09799-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Bonnie A Armstrong
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada.
| | - Dan Nemrodov
- University of Toronto Scarborough, Toronto, ON, Canada
| | - Arthur Tung
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada
| | - Simon J Graham
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, M4N 3M5, Canada
| | - Teodor Grantcharov
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Surgery, Clinical Excellence Research Center, Stanford University, Stanford, USA
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Tjønnås MS, Das A, Våpenstad C, Ose SO. Simulation-based skills training: a qualitative interview study exploring surgical trainees' experience of stress. ADVANCES IN SIMULATION (LONDON, ENGLAND) 2022; 7:33. [PMID: 36273197 PMCID: PMC9588224 DOI: 10.1186/s41077-022-00231-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/09/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Stress can affect the ability to acquire technical skills. Simulation-based training (SBT) courses allow surgical trainees to train their technical skills away from stressful clinical environments. Trainees' subjective experiences of stress during SBT courses on laparoscopic surgery remains understudied. Here, we explored the subjective stress experiences of surgical trainees during mandatory laparoscopic SBT courses. We aimed to obtain a broader understanding of which factors of the simulation training the trainees perceived as eliciting stress. METHODS A qualitative study with semistructured individual interviews was undertaken to explore trainees' subjective experiences of stress. Twenty surgical trainees participated while attending courses at a national training center for advanced laparoscopic surgery. Questions explored trainees' stress experiences during the SBT courses with a focus on perceived stressors related to laparoscopic simulation training on two box-trainers and one virtual reality simulator. Interview data were analyzed using inductive, qualitative content analysis methods to identify codes, categories, and themes. RESULTS Findings indicated that trainees have a variety of stress experiences during laparoscopic SBT. Three main themes were identified to be related to stress experiences: simulation task requirements, psychomotor skill levels and internal pressures, with subcategories such as task difficulty and time requirements, unrealistic haptic feedback and realism of graphics, inconsistent and poor technical performance, and self-imposed pressures and socio-evaluative threats. CONCLUSIONS Insights into surgical trainees' experience of stress during laparoscopic SBT courses showed that some stress experiences were directly related to simulation training, while others were of psychological nature. The technical and efficiency requirements of simulation tasks elicited stress experiences among trainees with less laparoscopic experience and lower levels of psychomotor skills. Self-imposed pressures played an integral part in how trainees mobilized and performed during the courses, suggesting that levels of stress might enhance laparoscopic simulation performance. For course facilitators aiming at optimizing future laparoscopic SBT courses, attending to the realism, providing clarity about learning objectives, and having awareness of individual differences among trainees' technical level when designing the simulation tasks, would be beneficial. Equally important to the laparoscopic SBT is to create a psychological safe learning space in order to reduce the internal pressures of trainees.
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Affiliation(s)
- Maria Suong Tjønnås
- Department of Neuromedicine and Movement Science (INB), Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, N-7491, Trondheim, Norway. .,SINTEF Digital, Department of Health Research, SINTEF, P.O. Box 4760 Torgarden, NO-7465, Trondheim, Norway.
| | - Anita Das
- Department of Neuromedicine and Movement Science (INB), Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, N-7491, Trondheim, Norway
| | - Cecilie Våpenstad
- SINTEF Digital, Department of Health Research, SINTEF, P.O. Box 4760 Torgarden, NO-7465, Trondheim, Norway.,Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, N-7491, Trondheim, Norway.,The national research center for Minimally invasive and Image-guided Diagnostics and Therapy (MiDT), St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 5, Postbox 3250 Torgarden, NO-7006, Trondheim, Norway
| | - Solveig Osborg Ose
- SINTEF Digital, Department of Health Research, SINTEF, P.O. Box 4760 Torgarden, NO-7465, Trondheim, Norway
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Does speed equal quality? Time pressure impairs minimally invasive surgical skills in a prospective crossover trial. Int J Surg 2022; 104:106813. [DOI: 10.1016/j.ijsu.2022.106813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 11/15/2022]
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Torkamani-Azar M, Lee A, Bednarik R. Methods and Measures for Mental Stress Assessment in Surgery: A Systematic Review of 20 Years of Literature. IEEE J Biomed Health Inform 2022; 26:4436-4449. [PMID: 35696473 DOI: 10.1109/jbhi.2022.3182869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
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.
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Conlon A, Arnold R, Preatoni E, Moore LJ. Pulling the Trigger: The Effect of a 5-Minute Slow Diaphragmatic Breathing Intervention on Psychophysiological Stress Responses and Pressurized Pistol Shooting Performance. JOURNAL OF SPORT & EXERCISE PSYCHOLOGY 2022; 44:206-219. [PMID: 35468589 DOI: 10.1123/jsep.2021-0213] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 02/17/2022] [Accepted: 02/24/2022] [Indexed: 06/14/2023]
Abstract
This study examined the effect of slow diaphragmatic breathing on psychophysiological stress responses and pressurized performance. Sixty-seven participants (40 female; Mage = 20.17 ± 2.77 years) were randomly assigned to either a diaphragmatic-breathing, paced-breathing, or control group. Participants completed a nonpressurized shooting task and then received instructions about a pressurized version. Next, the diaphragmatic group was told to breathe at 6 breaths/min, the paced group at 12 breaths/min, and the control group received no instructions. Following a 5-min intervention period, participants completed the pressurized task while performance was assessed. Psychophysiological stress responses (e.g., cognitive anxiety, heart rate) were recorded throughout. Results revealed that diaphragmatic breathing had mixed effects on stress responses, with some unaffected (e.g., heart rate) and others reduced (e.g., cognitive anxiety), and little effect on performance. Findings suggested that slow diaphragmatic breathing might not aid pressurized performance but could benefit psychological stress responses.
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Affiliation(s)
- Aodhagán Conlon
- Department for Health, University of Bath, Bath,United Kingdom
| | | | | | - Lee J Moore
- Department for Health, University of Bath, Bath,United Kingdom
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Hardie JA, Hunn D, Mitchell TE, Brennan PA. Patient, Procedure, People (PPP): recognising and responding to intraoperative critical events. Ann R Coll Surg Engl 2022; 104:409-413. [PMID: 34939840 PMCID: PMC9157965 DOI: 10.1308/rcsann.2021.0193] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Intraoperative critical events are rarely experienced by individual surgeons but are commonly experienced at a workforce level. Finding unfamiliar or unexpected pathology, anatomy, haemorrhage or an iatrogenic organ or structure injury cannot be completely eliminated in the complex surgical environment. It is vital that an appropriate, safe response to these infrequent events takes place to prevent possible further harm to patients. This paper introduces 'Patient, Procedure, People', a tool adapted from aviation threat and error management (TEM) training. It allows surgical teams to improve situational awareness (SA), communicate effectively, flatten team hierarchy gradients and improve decision-making before responding to critical events. We review factors contributing to poor decision-making, with resulting errors. These include loss of SA (tunnel vision), acute stress reactions (fight-flight or freeze-hide) and limbic hijacking (surprise and startle events). Events may cause workload to increase beyond cognitive capacity, further exacerbating the situation. After completing initial actions to achieve a temporary 'place of safety', surgical teams may use the tool to effectively manage threat or mitigate error. Aviation is a high-reliability organisation that has pioneered human factors research and training. Airline pilots undergo regular simulated emergencies assessment, including mandatory human factors assessment. Although the complexities of the operating theatre do not currently lend themselves to high-fidelity simulation as in aviation, valuable transferrable lessons can be learnt from aviation's approach to TEM.
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Affiliation(s)
- JA Hardie
- Frimley Health NHS Foundation Trust, UK
| | | | | | - PA Brennan
- Portsmouth Hospitals University NHS Trust, UK
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A neurotechnological aid for semi-autonomous suction in robotic-assisted surgery. Sci Rep 2022; 12:4504. [PMID: 35296714 PMCID: PMC8927583 DOI: 10.1038/s41598-022-08063-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/23/2022] [Indexed: 11/08/2022] Open
Abstract
Adoption of robotic-assisted surgery has steadily increased as it improves the surgeon’s dexterity and visualization. Despite these advantages, the success of a robotic procedure is highly dependent on the availability of a proficient surgical assistant that can collaborate with the surgeon. With the introduction of novel medical devices, the surgeon has taken over some of the surgical assistant’s tasks to increase their independence. This, however, has also resulted in surgeons experiencing higher levels of cognitive demands that can lead to reduced performance. In this work, we proposed a neurotechnology-based semi-autonomous assistant to release the main surgeon of the additional cognitive demands of a critical support task: blood suction. To create a more synergistic collaboration between the surgeon and the robotic assistant, a real-time cognitive workload assessment system based on EEG signals and eye-tracking was introduced. A computational experiment demonstrates that cognitive workload can be effectively detected with an 80% accuracy. Then, we show how the surgical performance can be improved by using the neurotechnological autonomous assistant as a close feedback loop to prevent states of high cognitive demands. Our findings highlight the potential of utilizing real-time cognitive workload assessments to improve the collaboration between an autonomous algorithm and the surgeon.
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Comment on the Mental Costs of Task Switching. Ann Surg 2021; 274:e908. [PMID: 33605594 DOI: 10.1097/sla.0000000000004787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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