Stepping up to the free throw line, Toronto Raptors basketball players may find Dana Sinclair’s advice on their minds: to control their self-talk and lower tension. “The pressure shifts – the skills don’t,” says the sports psychologist, who has worked with the team, along with others, from the Toronto Maple Leafs to the Canadian Olympic team.

“Under pressure, people tend to get tense, and then their thinking shifts to distraction, negative thinking, fear of failure,” she says. Sports psychology helps them practice and perform better, especially under stress.

These techniques have been used among professional athletes for decades. But it’s only recently that sports psychology has also been applied to other high-pressure, high-performance roles, such as CEOs, musicians and actors – and, now, surgeons.

“The thing [those jobs] all have in common is the need for excellence and pressure. In sports psychology, you’re trying to turn pressure into growth and development,” says Peter Jensen, a sports psychologist and corporate performance coach who has spoken to surgeons and staff at hospitals across Canada for over a decade.

This year, Sinclair brought her techniques to the operating room. A small study found that University of Toronto general surgery residents trained in visualization were more effective than those who had standard training. It suggested mental imagery may be a useful, low-cost addition to the regular curriculum. Based on that success, starting this spring, all University of Toronto junior general surgery residents will be trained in visualization techniques.

Using sports psychology in surgery

Research has shown sports psychology can reduce stress and boost performance among athletes. Visualization is one of the most commonly used techniques. A 1997 meta-analysis found that mental imagery is effective in athletes and works both as a replacement for practice and as an addition to it. It also found that both coaches and players liked using it. But it cautioned that much of the research was of variable quality, using small sample sizes and single-subject designs.

Though it’s not known exactly how visualization works, Sinclair says her favourite theory is that “you are activating your neural pathways – the same neural pathways that you would if you’re actually executing the activity. So basically you’re practicing without actually having to perform.” Many also believe it decreases stress levels by having users feel more prepared.

The evidence behind using sports psychology – also known as performance psychology – in health care is weaker. That’s partially because its use in health wasn’t considered until recently. A review of the literature on visualization found that the idea of it working in surgery makes sense. “[It] has been shown to both improve performance and decrease anxiety and thus offers a kind of learning with the potential to be more efficient and effective than the traditional apprenticeship model of surgical education,” it reads. But while there is evidence it works in basic suturing, cystoscopies and laproscopic surgery, other research found no effect. That leaves the benefits of mental practice for surgeons “unclear based on the current research,” according to the review.

Many surgeons, including St. Michael’s Hospital’s Teodor Grantcharov, mentally review upcoming surgeries before starting their day. “I stay for five minutes in bed or in the shower, and think, what are the patients I’m going to operate on today, what can I expect, what would I do if this or this happened,” he says. That’s one of the reasons he was interested in studying the value of a more formal version of mental practice.

Grantcharov’s study was one of the first randomized trials on the topic. Lead researcher Marisa Louridas recruited 20 senior surgery residents and randomly assigned half to use visualization techniques, instructing them to review a written script for a portion of Roux-en-Y gastric bypass surgery created with the input of bariatric surgeons. They included a description of what the surgeons saw and felt at each step, along with possible pitfalls.

Charles de Mestral was one of those residents, and said he found the scripts helpful in thinking through the details of every step. “For instance, when we’re suturing the bowel ends together, the sutures have to be tight. Visually, every time you take a bite [place a suture], you want to see the bowel loops tighten under the string.”

After reviewing the scripts for a week, all the students performed a surgery on pig bowel in a virtual operating room. The operation included an unexpected complication – an anaphylactic reaction to preoperative antibiotics. The group with the visualization did 25% better under the stress of the complication.

Potential uses

With the new limitations on the number of hours residents can work, creative training approaches are becoming more important, increasing interest in options like simulation labs and mental training.

“In surgery, we put a lot of effort into training surgeons on the technical aspects of the skills. But we don’t seem to spend [enough] time in terms of the cognitive or mental preparation for surgery,” says Tulin Cil, a surgeon at Women’s College Hospital.

There has also been a push towards more objective, hands-on skill measurement of surgeons. The Royal College of Physicians and Surgeons of Canada is moving toward a “competency-based” program. “We would like to see much more work-based assessments,” says Kenneth Harris, executive director of the College’s office of specialty education.

There’s a similar feeling that continuing education for surgeons already in practice needs to be more rigorous. Grantcharov has been pushing for more lifelong training for surgeons by including airplane-like black boxes that would help them catch mistakes and get feedback. Surgeon and writer Atul Gawande opined in a New Yorker piece that coaches and sports psychology techniques may be the answer to that need.

In fact, the research suggests experienced surgeons are exactly where coaching and sports psychology may be most beneficial. Though most research in medicine has been around improving the performance of those still in training, much of the research around performance psychology in athletes has found it works best in elite players.

But despite continuing education requirements, doctors have little experience with lifelong testing and feedback. “It’s possible that once you’re certified, you could never work with another surgeon in your life,” says Harris, adding that feedback programs are always beneficial. “I was fortunate to work in a practice where we worked with other surgeons on cases, and I always picked up something, even though I’d been in practice for 20 years.”

Harris is also among those surgeons who automatically reviewed upcoming surgeries in his mind. “I think there is evidence that mental practice enables the procedure to go better,” he says. “It makes sense to me, as part of a whole spectrum of things that you could to do in addition to standard training.”