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Psychological Theory as It Applies to Surgical Training

Babchenko, Oksana, MD; Garland, Catharine B., MD; Bentz, Michael L., MD, FAAP, FACS; Poore, Samuel O., MD, PhD

doi: 10.1097/SLA.0000000000003180

Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin – Madison, Madison, WI.

Reprints: Catharine B. Garland, MD, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, G5/361 CSC, Madison, WI 53792. E-mail:

Brief Description: This SURGICAL PERSPECTIVE focuses on what constitutes an optimal Resident Training Environment, which we define as a combination of resident–faculty interactions, operating room teaching approaches, and local (eg, departmental) surgical culture. This perspective reviews relevant articles and foundational research studies from neuroscience, psychology, and education, an understanding of which is paramount to improving surgical training.

The authors report no conflicts of interest.

Surgical education has traditionally focused on technical aspects of surgical skill acquisition, for good technical skills are the building blocks of surgery. Cultivation of the psychological aspects of being a good surgeon—such as self-confidence, ability to handle stress, and resilience—has received much less attention in the educational context. Furthermore, achievement of these goals while retaining one's humanism, collegiality, and personal well-being, has not yet been collectively considered. We believe much of these “subtler” lessons are implicitly passed through surgical culture. Local surgical culture, which extends to the wards and the operating room, may also affect surgical training in ways that we have not yet considered.

We define Resident Training Environment (RTE) as a combination of resident–faculty interactions, operating room (OR) teaching approaches, and local (departmental) surgical culture. Below, we explore the optimal RTE by applying findings from neuroscience, psychology, and education research.

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Neuroscience research has consistently demonstrated that working memory and attention are crucial for learning and performance. Cognitive Learning Theory (CLT) states that learning a new task is optimized with full attention, when one's working memory is free from distractions and focus is on the task-at-hand. Conversely, distractors impair learning by loading working memory with extraneous cognitive load.1 Literature on surgical judgment has explored a similar concept of limited mental “spare capacity” in the novice surgeon.2 Furthermore, the type of distractions matter, with adverse, fear-based emotional distractions being the strongest hijackers of attention.3

These findings suggest that hostile operating room environments, including practices such as berating or shaming the trainee, likely inhibit resident learning by causing emotional distractions that hijack concentration. The optimal RTE, especially for the novice learner, is one where the learner's full attention and working memory can be focused on learning and performing the operation.

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Workplace incivility (rudeness) undermines a culture of safety,4 is associated with resident attrition,5 and is a major contributor to burnout.6 Rudeness is found to have adverse effects on both the diagnostic and procedural performance of doctors and nurses.7 In the nonmedical world, workplace incivility is found to be associated with decreased work effort, decreased work quality, decreased creativity, decreased team spirit, and decreased commitment to the organization. Even the act of observing rudeness is shown to worsen memory and creativity tasks.8

Incivility affects resident education in 2 major ways. First, incivility contributes to burnout, and burnout detracts from a learner's ability to learn and perform to their full potential. Second, in the OR environment, incivility functions as an adverse emotional distractor, hijacking attention, and thus impeding learning and performance.

A positive RTE may buffer against both resident and faculty burnout. A positive RTE reduces needless emotional distractors, allowing focus to stay on the operation. Finally, a positive RTE may enhance resident confidence, unlike rude environments.

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Substantial evidence suggests that feelings of anxiety and powerlessness (ie, lack of self-confidence) are disruptive to learning and performance. Learning and memory formation are complex phenomena requiring both repetitive skill acquisition and optimization of neuronal processes. While increased epinephrine and norepinephrine in heightened emotional states enhance memory formation, a shift toward anxiety or fear impairs working memory, memory retrieval, and other higher-order cognitive functions.9 In such fearful states, neuronal resources are reallocated toward more primitive cognition such as the “fight or flight” response.10 Similarly, feelings of powerlessness (ie, lack of self-confidence) also impair higher-order cognitive functions and worsen performance.11 In an anxious or powerless state, one cannot fully meet the demands of complicated situations that require higher-order cognition such as judgment, flexibility, and cognitive agility.11 The difference between a heightened emotional (ie, excited) state and fearful/anxious state is important to identify, as one can be a promoter and the other a detractor to optimal learning and performance.

In contrast, feeling confident and capable enhances learning and performance. Studies on power generally reveal that when subjects are “primed” with power (ie, boosted confidence), they have improved performance and increased perseverance.12 Furthermore, when an individual feels powerful, stressful situations have paradoxically been found to enhance performance, as stressors are seen as challenges rather than threats.12,13

In light of these findings, confidence is beneficial to residents during surgical training. At our own institution, we found our residents unanimously view self-confidence as important to training (data not yet published). Overall, graduating surgical residents tend to report suboptimal levels of operative confidence, with female trainees tending to report even lower levels than their male peers.14 A changing training environment that affords less resident independence has been identified as one major obstacle in building resident operative confidence. Although studies on strengthening resident confidence are few, operative repetition including simulation environments,15 and teachers’ direct influence on residents’ self-perceptions,13 likely play significant roles.

Given the positive effects of confidence on cognition and performance, especially in high-pressure situations, we urge faculty to teach in a way that inspires resident confidence. Below, we explore how to inspire confidence while maintaining the crucial role of constructive criticism.

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Modern social psychology research has demonstrated the crucial roles that self-esteem and motivation play in learning. The “Growth vs. Fixed” mindset theory of Carol Dweck details this phenomenon.13 The theory describes 2 basic ways that people tend to think about their abilities. In the growth mindset, one believes that her abilities (talent, intelligence, etc.) can improve with enough effort and correct strategy. In the fixed mindset, one believes that her abilities are fixed traits, and thus cannot be significantly changed.

The response to challenges differs in these 2 mindsets. The growth mindset helps one rise up to challenges. If one believes his talents and abilities can grow, he views challenges and failures as opportunities to seize, learn, and improve. This reaction is termed the mastery-oriented response. The fixed mindset instead stifles the individual when he encounters challenges and failures, by his own assumption that real growth is not possible. If one believes that his talents and abilities are fixed traits, failures are perceived as negative reflections on his permanent self (ie, “I am a failure.”). Challenges and failures have adverse effects on “fixed-mindset” students, lowering self-esteem, motivation, and future performance. When given the choice, students in fixed mindsets often avoid challenges. This is termed the helpless response. Psychology research has shown that a teacher's feedback approach can nudge students to either mindset (growth vs fixed), and thus affect how those students respond to future challenges.

Dweck found that constructive criticism, when specifically targeted, aligns with a growth mindset. In contrast, criticism aimed at the person's “self” promotes a fixed mindset, for it condemns the person as a whole. Criticism directed at the specific task-at-hand allows the learner to refine their technique without the discouraging weight of believing that in some way, they are hopelessly deficient. For example: “That's the wrong plane; see that fat is different? Now find your way back to the right plane. […] Nice.” rather than, “You are in the wrong plane again. You never see planes well. […] Just give me the Bovie.”

Similarly, praise should be directed toward effort and improvement, rather than seemingly intrinsic qualities such as talent or intelligence. Praise toward effort and improvement pushes the learner to a growth mindset, for it highlights that improvement is possible and is in the learner's hands, inspiring motivation and drive to keep going toward the goal. Furthermore, when a student feels that her teacher is excited for her improvement, it motivates her as she sees that the teacher is invested in her growth. Praise toward talent and intelligence, conversely, nudges the learner toward a fixed mindset. If the learner is labeled as “talented” this may become his identity. Subsequently, challenges and failures are threats to this identity, rather than opportunities from which to learn and grow.

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A positive RTE that limits emotional distraction and cultivates a growth mindset may help us produce both competent and confident surgeons. A positive OR culture reduces adverse emotional distractions, allowing the resident to direct full attention toward the operation, optimizing learning. A positive culture buffers against burnout, avoidance of which is vital for individual and organizational success. A positive culture is conducive to cultivating resident confidence, and confidence is key for both cognition and performance. Finally, teachers’ feedback has been shown to influence students’ future responses to challenges, highlighting the importance of cultivating a growth mindset in the learner.

It is well established that significant variability in learning styles exists between individuals. While it is beyond the scope of this paper to discuss all of these, the development of a positive RTE should be a fluid process between the faculty and resident, incorporating both of their personalities, dynamics, and the resident's learning styles. Many positive and productive RTEs are possible, unique as the individuals who create them.

As surgical teachers, we are not only training the hands, but also the mind and heart. In general, there is a lack of emphasis on training nontechnical surgical skills. We commend the development of assessment tools such as NOTSS (Non-Technical Skills for Surgeons) that are aimed at assessing these critical, nontechnical proficiencies.16 We advocate that faculty not only teach technical skills, but also help residents become surgeons in their own minds. This includes helping them gain confidence and ability to handle stress, and just as importantly, showing them how to maintain their humanism in this demanding profession, including preserving collegiality, well-being, and empathy. We believe a good place to start is with a positive resident training environment. Surgical faculty set the example; the surgical culture we create becomes our legacy and our residents’ inheritance.

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growth mindset; operating room teaching; residency teaching; residency training; residency training environment; surgical culture; surgical education; surgical training; workplace incivility

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