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The story behind the paper “Absence of Stressful Conditions Accelerates Dexterous Skill Acquisition in Surgery” in Scientific Reports

February 8, 2019


Left: One of the medical students who took microsurgical training as a hobby; he is practicing suturing. Right: Facial thermal image of the student along with the extracted perspiration signal, indicating moderate stress levels.

Back in 2008 I got an NSF grant to conduct research on the effect of stress on surgical training. It was collaborative work with Dr. Bass’s group at the Methodist Hospital that lasted three years.  Importantly, it was marking the first field study that my lab performed using the novel stress-measurement methods we developed in the 2000s. The methods were based on quantification of facial perspiration levels through thermal imaging.

The project culminated with a publication in Scientific Reports in 2012, where we documented that surgical residents under stress attempt surgical drills mindlessly fast, leading to a vicious cycle of errors and more stress. I called this phenomenon `sympathetic looping’ and appeared to wreak havoc in dexterous skill acquisition – after five training sessions in a simulator, surgical residents were in the same position as in their first session.  It dawned on me that fight or flight responses were a mismatch to subtle dexterous manipulations that underlie human civilization – a nemesis to dexterous skill acquisition and the culprit of major accidents in surgery and aviation.

The sources of stress afflicting surgical residents during training was a question that intrigued me. On the one hand, surgical residents were operating in a stressful environment. On the other hand, the laparoscopic drills they were practicing were also stressful due to loss of proprioception. It was not clear which stress factor contributed the most to the generation of sympathetic looping. I slowly formed the opinion that the stressful environment was the primary factor and the challenging nature of the drills the secondary factor. In the summer of 2014 we reached out to high school students and asked them to come to the Methodist Surgery Department to get trained on surgical simulators. It was not a formal study or a rigorous training program, just an outreach activity in the form of a fun summer camp. What I casually observed, however, strengthened my belief that environmental conditions was the culprit of sympathetic looping. The students  were performing unbelievably well while they were having a great time.

Efforts to secure NSF funding for a follow-up investigation along these lines failed, and I thought my hypothesis would never be tested. Circa  2016, Dr. Echo, a young surgeon from the Methodist Institute for Reconstructive Surgery asked me to collaborate and expand the work I did with Dr. Bass back in the early 2010s. I discussed with him what I had in mind and explained that we needed some money to get started. He said we could possibly get a small amount through the Plastic Surgery Foundation. No rational investigator would have committed to start such a challenging research project on a minuscule budget. I guess, I took an emotional rather than rational decision and I accepted to move on. Anthony was successful in securing this small grant and the project started.

Anthony and his new assistant surgeon, Dr. Dmitry Zavlin, were enthusiastic and this kept me going. They had the idea to use first year students from the Baylor College of Medicine, as they found the idea of using high school students extreme and non-practical. So, we did. Ashik Khatri and Amanveer Wesley form my lab ran the longitudinal study. To emphasize the informal character of the training, the student participants were coming to practice the surgical drills in our lab at the University of Houston – not at the Methodist Hospital or the Baylor College of Medicine.

By the time we collected the data nearly a year had passed and we were choking under excessive research load from federally funded projects. I saw the danger of not being able to do the analysis and shelving this line of research. Hence, I came up with a creative idea – I formulated the analytic design, and gave it to my Teaching Assistant, George Panagopoulos, to execute it as a semester-long project for my Statistical Methods class. Then, under our supervision, the class with its ten teams executed the analytics, confirming George’s results and learning a lot in the process through exposure to an interesting research problem. After the end of the semester, I had the opportunity to further refine the analysis with help from Amanveer and Ashik. Once we received the reviews from Scientific Reports (Sci Rep), we proceeded with further refinement, which gave the paper its current form.

Stress results were crystal clear and were supported not only from physiological, but also from psychometric analysis – the students did not exhibit undue stress during the training sessions. Performance results, reported by two expert raters, were also crystal clear – the students attained surgical competence in five short sessions. Back in the 2012 study, stressed residents were nowhere near competence levels after five sessions. In all, the Sci Rep 2019 results nicely complemented the sympathetic looping theory we reported in Sci Rep 2012, suggesting also a solution to the surgical training problem: render dexterous training an extracurricular activity for aspiring surgeons, long before they enter stressful surgical residency programs.


The paper can be accessed at: Pavlidis et al. Sci Rep 2019 

The outreach site can be accessed at:  Outreach for Sci Rep 2019



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