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Excellence in Surgery: Psychological Considerations

By Judy McDonald & Terry Orlick




The purpose of this study was to assess mental factors related to performance excellence in surgery. Interviews were conducted with 33 active surgeons representing six surgical specialties. Participants were identified by heads of surgery departments as being highly proficient in their specialty. Interviews were conducted one-on-one face-to-face at the surgeon's convenience in his or her office or in a spare office at the hospital. The success elements from Orlick's "Wheel of Excellence" were used as the basic framework for the qualitative analysis of the transcripts. All seven elements of excellence outlined in Orlick's model, commitment, belief, positive imagery, mental readiness, full focus, distraction control, and constructive evaluation, were clearly evident for elite surgeons. Interview excerpts presented demonstrate how elite surgeons acted on the seven elements of excellence.

In high-risk surgery, a surgeon's focus and diligence are essential; the patient rarely gets a second chance. With a life at stake, knowing how to operate under extremely stressful conditions and consistently perform to one's capacity is crucial.

Although the technical aspects of surgery are well documented, little research has been conducted on mental readiness strategies in surgery. Wind and Rich (1983) highlighted behavior patterns and personality traits of "good surgeons," which included attention to details, calmness, logical thought under stress, and effective leadership. Others have studied the importance of assuming responsibility and developing coping skills (Barber, 1971; Davis, 1987; Holden, 1985; Spencer, 1983; Wright, 1984). Support for the value of mental training principles among medical professionals has emerged from the research on the use of visual memory images for learning anatomy (Gibbons, Baker & Skinner, 1986; Horowitz, 1983; Korn, 1983; Najarian, 1989). Acute observation, visualization in three dimensions (Najarian, 1989), and constructing both visual and kinesthetic images (Korn, 1983) were identified as critical for learning surgical procedures and performing appropriate motor skills. The limited amount of medical literature on mental preparation for surgery suggests the need for further research in the area of mental readiness and excellence.

Orlick’s "Wheel of Excellence" formulated a conceptual framework for the pursuit of excellence based on the results of in-depth interviews with world-class athletes (Orlick & Lee-Gartner, and Orlick & Partington), as well as ongoing work with individuals engaged in other high-performance pursuits (Orlick, 1990, 1998). The seven elements of excellence in the model include commitment, belief, positive imagery, mental readiness, full focus, distraction control, and constructive evaluation. The purpose of this study was to determine the extent to which these seven elements of excellence exist in the surgical arena.



Sample Selection

The interview sample consisted of 33 currently active surgeons-26 men and seven women. The heads of surgery departments at five hospitals identified these surgeons as highly proficient in their specialty. Six surgical specialties were represented. They were grouped as having either high mortality risk (51%: neurosurgery, cardiac surgery, and vascular surgery) or low mortality risk (49%: orthopedic, general, and plastic surgery). Years of experience ranged from one to 30, with a mean of 11 years; 49% had over 10 years' experience, 36% had four to nine years, and 15% had one to three years. Fifty-five percent operated on adults, 30% were pediatric surgeons, and 15% did both. Seven surgeons had a reputation among their peers, the medical community, and the media as being elite or superstars.



A "surgeon interview guide" was created specifically for this study. Questions were adapted from Orlick and Partington's (1988) high-performance athlete interview guide and pilot-tested with four leading surgeons. Questions related specifically to mental preparation for surgery, including concentration, mental rehearsal, crisis management, and development of specialized thinking patterns. The surgeons were asked to list examples of challenging high-performance conditions in surgery. Seven circumstances were identified where elective surgical procedures were judged to be complicated, stressful, and/or high risk. These challenging surgical procedures included high-risk procedures, complex procedures, high-risk patients, teaching others, first-of-its-kind procedures, unfamiliar procedures, and special patient relationship pressure.



Interviews were arranged through a letter and a follow-up telephone call. The letter explained the purpose of the interview, introduced the investigators, and provided assurances of confidentiality within the framework of the proposed design. The interviews were one-on-one, face-to-face, one rime only, and were arranged at the surgeon's convenience. The interviews were held in the doctors' office or in a spare office at the hospital. The surgeons were free to respond to each question in an open-ended way. Bach interview was tape-recorded with the permission of the respondent. Following completion of all the interviews, verbatim interview transcripts were prepared for descriptive analysis. All surgeons received a copy of their interview transcript to verify its authenticity.



Ten transcripts representing surgeons of different specialties, level of experience, and gender were reviewed by the investigators to extract representative quotes indicative of the existence of each of the seven elements of excellence. A short definition of each element along with the representative quotes were then given to and studied by four independent reviewers. They then independently read through all 33 transcripts to determine which success elements were evident for each subject. There was full agreement between the reviewers with respect to whether or not a particular surgeon's transcript contained each of the major success elements.


Results and Discussion

Surgeons' views on the importance of mental readiness and other mental factors related to success in surgery are presented below as they relate to the elements of Orlick's "Wheel of Excellence": commitment, belief, positive imagery, mental readiness, full focus, distraction control, and constructive evaluation. Representative interview quotes are presented to bring the reader closer to the data and illustrate the basis on which categories were formulated.



All surgeons exhibited a high level of commitment. This commitment was evidenced by giving extra time, being dedicated to their profession, being persistent and meticulous in setting high standards, and staying open-minded and compassionate. For 72% of surgeons, their commitment was also related to feeling personally responsible for and fearful of errors.

You can't be a part-time surgeon. To do surgery well you have to be full-time and you have to be totally devoted to it. That has to be your main thing. If you take it as a hobby or a part-time thing, I

don't think you do it as weIl...Of course it makes your life really narrow but that's what you've chosen to do... You do only one thing; you're not into a lot of diversion. Some people are trying to be administrators and other things and doing surgery part-time. I don't really think that works out too well... You really have to be totally dedicated. I think it's just like training for any sport. It's a full-time training thing. It's a regimented routine. You're doing a lot of surgery. You're not out messing around. (elite orthopedic surgeon)

Always, always, the bottom line is the patient. You need to keep that focus in mind... I have a supportive family so if I'm late for an engagement in the evening, that really doesn't make a difference. My wife understands and all my friends understand... You've got to realize and keep your priority there. Everyone else will actually understand. Those that don't understand you don't have to worry about. You have to take that attitude, the patient comes first. .I get called all the time when I'm not on call. I come in because that's the bottom line. Everybody around who deals with me knows that I will go. There are no if's or but's. (elite neurosurgeon)

We [young surgeons] still have one foot in the old era, where mental readiness demands dedication. It's not uncommon for a lot of the old-time surgeons to say, "Surgery comes first, and my family comes second"...We are at the threshold of a new era, where the newer residents believe, whether right or wrong, that lifestyle and family is first and surgery comes second. (cardiac surgeon)



All surgeons interviewed projected a strong belief in themselves and their surgical ability. They felt that confidence was something they acquired through experience. The majority of surgeons enhanced their own confidence by devising ways to control what was controllable within their environment. For example, they developed effective procedures, used positive thinking, picked their own team, and derived ways to postpone or cancel surgery when more preparation time was needed.

Every step that goes well is a building process. Every small successful step builds me up for the next step. Once I arrive to the area of the tumor I say, "Gee, it's in my view" Something that has been successful to that point should be successful to the end. It's a build-up of confidence. It's not just there. (neurosurgeon)

I'm not the best surgeon in the world,...but I feel competent I know I've done my homework. Hence, I' m surgically and mentally prepared. It's not easy The stress is still there, but not the anxiety of not being capable of performing. The stress of doing something difficult will pass. I'm prepared and I know I'm capable. Otherwise, I would not be able to function. If I had no confidence in myself, what would I be doing in the operating room? (cardiac surgeon)

Mentors, the kinship of fellow surgeons, and faith were also strong factors in enhancing confident performances.

It's a matter of emulating your masters. If you respect a surgeon's judgment and skill then you try to be like him or her You develop confidence when you know you're learning from the best (elite neurosurgeon)

You have to have "a brother" [fellow surgeon]... Our first 10 years of practice we talked about everything, every case. Every time we'd have a disaster we'd be on the phone to each other. You dump your soul then you feel better and go at it again. Otherwise you might be shy to get back on. (neurosurgeon)

When I'm in times of trouble, sometimes I say "God help me." I say it to myself during surgery. For me it helps because I strongly believe. You have do your homework, but there is a factor where there is something else in control. Your belief plays a role in your mental preparation and your spiritual preparation. (elite neurosurgeon)


Positive Imagery

The criteria for evidence of positive images were very stringent. The surgeons had to make statements about visualizing, imagining, creating mental pictures, running a movie, or feeling the tissue in ones mind's eye, as opposed to just positive thinking or planning. Virtually all surgeons reported engaging in positive thinking, but not all reported translating those thoughts into clear imagery. Positive imagery was a common practice in mental preparation before surgery and for performing through difficult phases. Mental imagery was reported by 79% of surgeons either before or after surgery. It was used by 73% of surgeons for rehearsing in preparation and by 27% for recalling and evaluating performance details. Imagery was also used in coping with negative consequences.

An interesting finding was that all of the most exceptional or elite surgeons made extensive use of mental imagery. Surgery lends itself well to creating and rehearsing visual and tactile experiences. The most effective images were vivid, replete with sensory experiences, and often focused on executing the following tasks:

My motto is to visualize. For instance, I visualize myself cutting the skin and the fat, seeing what muscles are underneath, knowing what instrument l'll use to cut with. Then l'll think, "Oh yes, remember to get your cautery out, to burn the muscle instead of cutting it so you don't get complications afterwards with your blood clotting [the hematoma]. "I just visualize what I'm doing... When I was first starting out and doing a cleft lip, where I was operating on a baby's head upside down, I'd do my drawings upside down. I always have a visual picture in my head when I' m doing something as to how I'm going to do it. It's like seeing all the tissues in three dimensions... A lot of the time I'll actually remember how it felt, how much I had to press, and how much I had to handle the tissue to get to the right spot If you're in the right spot, often it is very easy to do what you want it to do. If you're not in the right spot, it's hard... The "feel" of it is part of it (general surgeon)

I have an idea as to what the perfect inside should look like. Each time you're trying to reproduce that as close as you can. With orthopedics, it's never perfect. It's a little like carpentry: You shave a little off, put it together and match it We use saws, drills, and all that kind of stuff, so it can never actually be perfect Some of the residents use that word. They say "Oh, that's perfect" It's pretty good but it's not perfect. There's that idea of perfect and then there's what you can actually achieve with whatever tissue you are working on. (elite orthopedic surgeon)

I've rehearsed all the potential scenarios that I'm familiar with given my experience and based on the communication with others. I've also worked through contingency plans in my mind. If it's a planned elective procedure, my most intense period is the night before at home, and then often the half hour or the hour that the patient is actually being prepared for surgery and anesthetized. I do most of it when I'm on my own and then I review my options again in the operating room, with the x-rays right there in front of me, in case I've overlooked or forgotten some simple little detail... I'd say my visualization is 80% visual and 10% motor and other sensory parameters... It's 3-D imagery. "Where is everything going to be? What am I going to encounter?" I can sit right here in the office, or I can be driving the car or be anywhere at all. I can just turn on the cameras and I can do 3-D imagery. I rotate it around in different planes almost like a hologram because that's what surgery is all about You don't necessarily just go in on one trajectory. The trajectory may change according to how you move your instruments around. So I do an awful lot of imagery before surgery... It comes so natural to me, I assume that many others use it.,. I've always been a 3-D person. It's just a very natural process for me. (elite neurosurgeon)

Mental imagery was viewed by some of the exceptional surgeons as an essential or critical skill that develops with practice and experience.

When I first began, I was less into mental imagery. Of course, then my contingency plan preparation was far less elaborate than it is now I think you build upon every case. (elite neurosurgeon)


Mental Readiness

Surgeons were asked to recall their preparation activities prior to a recent successful performance in surgery. The intent was to determine what preceded best performances. All surgeons reported that in their best performances they had planned a series of activities leading to a positive state of mental readiness.

Seventy percent of surgeons mentioned that it was essential for them to take some quiet time to prepare themselves mentally before operations. During this time they were usually engaged in positive thinking, reviewing their plan, anticipating possible complications, reflecting on constructive solutions and giving themselves reminders to focus on the right things.

You can overcome just about anything if you're properly prepared for it mentally. When the operation starts, you can shut everything out of your life if you're ready for it When people come apart mentally it's because they haven't taken enough time to prepare for when they're in there. Then they realize that they're into something they don' t completely understand. That's when it comes apart. (elite cardiac surgeon)

The mental preparation is as important as physically being there. In other words, if you're not with your case, if you're not positive about it, and if you have not convinced yourself that you can do this and give the patient a reasonable chance of improvement, then I don't think you should be doing the surgery This comes from mental preparation, training, and attention to detail for every case. It's not hit-and-miss. You have to produce it every time. (orthopedic surgeon)

I would give a very very high priority to mental readiness as it applies to your overall knowledge, experience, and overall preparation for this given event. It would probably be higher than the technical preparation because mental readiness involves the technical preparation. It's everything. It's the confidence of knowing that you have done everything that can be done before you go in there, that you have prepared yourself as well as you possibly can, and that you know you can do it (elite cardiac surgeon)

I've been called a nit-picker; People around me have called me that. Before we did the first transplant we went over and over and over it I insisted on full team meetings. Some people thought it was excessive. The thing is, you can't afford not to do it with these things because something will go wrong. The people who succeed in very complicated endeavors like that are people who are meticulous. People who fail are people who are not meticulous. Occasionally somebody who is not quite as meticulous will get away with something. But they won't get away with it consistently (elite cardiac surgeon)

You have to prepare yourself well for surgery You have to know what you're going to do. You also need a reflex for the unexpected things that can happen, and to suddenly be able to make a decision. (elite cardiac surgeon)

The decisions and the assessments done before are sometimes a lot more important than what you do during the surgery The decision-making process is sometimes more stressful than the actual surgical procedure. Once it's decided you just follow your plan. Sometimes the decisions aren't that easy (orthopedic surgeon)

Positive preparation gives purpose and direction to actions and helps provide stability in times of stress. Surgeons who said they set clear objectives before surgery reported fewer emotional reactions to crises and were able to refocus during a crisis I taking a moment to assess the situation and quickly recall back-up options.

Consulting with the patient and colleagues was also felt to be significant in tern of mental preparation.

You gain mental preparation by thoroughly discussing it with the patient (if you can) and the family. You're explaining and venting part of your fear of death or complications. In our case, it's usually the parents. Dealing with parents is a very tough business. You are accountable directly to them as to what you're doing to their child. The parents are not sick. The one that is sick is the child so the parents are in full command of their own mental abilities and demands... You have to gain the trust of that family If you feel and sense that you've gained their trust, then you feel a lot more secure and more confident in what you are doing... If this is not an emergency and I see the slightest hesitation from them I won't do it (elite neurosurgeon)

The best advice that I could give a younger surgeon is to develop as good a rapport with the patient and parents as possible. That makes it easier to discuss difficult situations afterwards. (orthopedic surgeon)

One thing I've kept in mind was, "What would I do if it was my father or mother brother or sister?" If you would do the same for them, then it should be applicable to this person. That is a good way of thinking. I find that gives me an assurance that I did the right thing. (elite cardiac surgeon)

Some surgeons also reported that exercise, good nutrition, and adequate rest prior to surgery predispose the surgeon to a better focus before and during surgery and lead to better preparedness and handling of crises.

You have to be in good health and you need the stamina. I'm not an athlete but I think I'm in excellent health and fitness... So I feel that I'm in shape. When I finish those long operations I don't feel beaten up. I'm tired maybe, but not beaten up. ..and I can do it again and again. (elite neurosurgeon)

In previous studies, surgery has been portrayed as a 'state of flow" or quiet concentration (Csikszentmihalyi, 1975), quiet white noise (Dawson, 1990), and a relaxed, positive mindset (Korn, 1983,). In the present study, all surgeons described the experience of being in a fully focused state during their best performances. This focus was characterized by complete concentration, the ability to anticipate the next step, and/or being able to direct their energy in a positive and focused way. Most often the fully focused state was accompanied by an absence of anxiety. The surgery took on a rhythm of its own and was experienced as very connected, flowing, and enjoyable.

The minute I'm in the OR I find the rest of the world can be blown up around me, and it wouldn't bother me. I find that the OR is like an oasis away from the world. (cardiac surgeon)

You have to be able to exclude other things from your mind at the time of crunch. You can't think about anything else when you' re faced with a major problem. As soon as you've overcome the difficult part 'of the surgery then I say "Let everything hang out!-joke, laugh, relax, or whatever".. but you've got to be ready You're at the starting line of a 100-yard dash in the Olympics. You have to have everything focused purely on the procedure. (elite neurosurgeon)

It's a matter of total concentration and not allowing emotion to enter into it During routine operations, it's wise to try to keep the atmosphere as relaxed as you can, especially with young trainees, to reassure them that you are supportive. Be friendly with them to inspire confidence in them. If they happen to go a little astray you bring them back gently, so there won't be a crisis. (elite cardiac surgeon)

If I'm doing a procedure that takes a lot of attention, I tend to be very focused. I don't see or hear anything that goes on around me. That's how I can tell when I am focused. I will just not be aware of anything. However; if it is something where my concentration is going in and out because it doesn't have to be in, I can chat with the nurses or my assistant. I'm still paying attention, but I don't have to be totally not thinking of anything else. If I'm doing a difficult part, then everything else gets shut out (orthopedic surgeon)

Having a dark room with the focus of light just on the patient's head or spinal cord where you're working is most relaxing. When you've got music and you've got that dim-lighting environment going, it's wonderful! I could be there all day (elite neurosurgeon)

I was feeling good. I think that makes a difference. You know when sometimes you don't feel right? It's not fun. If it's not fun, then it's difficult. (neurosurgeon)

You just have to keep going at a steady pace. Once you get to the clearing... you change pace... To me the rhythm is not wasting any moves...At that time of the operation, you don't talk. You concentrate and you look. That's where the rhythm comes in. You've been doing the hard physical work and all of a sudden, you have to go from grunting type of work to the very delicate, where you're passing wires around the spinal cord. Then at the end it gets physical again. (orthopedic surgeon)


Distraction Control

Distractions that prevent a surgeon from staying alert, focused, relaxed, and meticulous can quickly create a performance disadvantage. In recalling distractions that occurred during best performances, all surgeons reported getting back on track quickly. They were exceptionally well versed at maintaining a constructive focus during high action periods and during surgical crises. However, as a group, they were not as effective at maintaining a positive focus when faced with preoperative distractions or lulls in surgery.

Lulls were rated as the most common distraction-and the distraction for which surgeons had the least effective coping strategies. Dealing positively with this down time is an area that needs further attention. Surgeons developed a remarkable "emergency mode" that they had learned to enter quickly in response to a crisis. As one elite neurosurgeon expressed it:

I probably perform better in times of crisis than I do in the routine elective situations. All of a sudden you can feel that your perception, all your senses, and all your responses are at a much more elite level than they are in a routine operation.

Successful strategies for entering this fully focused state for crises situations included taking a brief "time out," positive thinking, assessing options, taking charge, and instructing others.

If something goes wrong that is catastrophic, the important thing is not to allow people to start jumping around and going hysterical. You just have to stand quiet, be in complete control, and keep totally focused on the area you're dealing with. I've gone through that many times. People will start jumping around and saying, "Get this and get that" I just say, "Be quiet Just take it easy We're going to do this, that, and that" and I just stand still. (elite cardiac surgeon)

Usually I stop everything. It may only be for a matter of a second or two, but mentally and physically I stop, and take stock. That usually prevents panic. (orthopedic surgeon)

When we get out of the problem we've been in, I tend to just stop for a few minutes. Usually then there is a sigh of relief from other members of the staff, the nurses, the residents, and so on. We always take a few minutes break,.. .possibly walking around the room, talking, and just generally patting ourselves on the back for how we got out of that jam. Stopping, taking stock, and discussing with the staff are often very good tension reducers. (elite neurosurgeon)

The most important rule followed by elite surgeons is prevention. They are advocates of properly preparing the patient and themselves for complications, cautiously planning each step, and carefully doing things right the first time.

I was prepared for failure, the patient was prepared for failure, and the son was prepared for failure. I decided to devote a lot of time to it that day and to approach it as slowly and as cautiously as I could every step of the way. I avoided getting into trouble with each step. On the way in, I avoided doing anything I couldn't undo. (elite cardiac surgeon)


Distraction Control Over Hindrances

Part of what allows highly competent surgeons to stay focused and deal constructively with distractions in the theater is the perspective they carry into that arena.

There are certain surgeons who think every little problem is a giant problem; they make it into a big flap. They're just not going to last You want to last a long time. It's like running a marathon; you've got to go in at a nice, slow easy pace. Just keep doing it. Keep trucking along and don't make all these little mountains out of mole hills. (elite orthopedic surgeon)

It's not uncommon to find that instruments are missing or that instruments break. We have such an "armormentarium of tools" that you can almost always do the operation with some other instrument. It may not be the most desirable or the most useful, but there are other instruments that you can use, and usually you can work around it (elite neurosurgeon)

I tell myself, "It's going to be all right The end result will be all right". If it's not as I thought, then I say "I didn't give this disease to the patient I'm not the cause of it. I'm doing my best. What I can do, I can do. I'm not God." These are the types of things that I silently tell myself. "I thought this was going to be good but the disease is not the same as I'd seen on the film." Sometimes when you go in, you wonder if it is the same patient anatomy that you saw in the angiogram... There's no faullt. (elite cardiac surgeon)

If you're tired you've been on call, or you've had a rough night, this will interfere for sure. Sometimes you'll find your judgment is worse. When I know I'm going to be on call for a long period of time, I try to avoid doing a delicate procedure the following day. It can affect your speed and judgment in that you feel you're not as efficient as you should be. (general surgeon)

"Normal" would be a positive. We've come to expect that something is not going to go right somewhere along the line and that you're going to have to accommodate yourself to it It's usually nothing that will compromise the patient, but it is a distractor to the smooth, efficient conduct of the operation. (elite neurosurgeon)

I feel I'm always a student and I'm always learning as I go along... I feel ready competence-wise in handling it and I am prepared to do it..l don't feel that everything's going to be guaranteed to go smoothly Once you stop learning, you should stop operating. (orthopedic surgeon)


Preoperative Distraction Control

Distractions before surgery present potential performance blocks and require effective skills to regain a positive focus. While all surgeons reported good refocusing skills for dealing with hindrances during surgery, only 85% felt competent in dealing with preoperative distractions.

As you become more mature, you realize that ranting and raving accomplishes nothing. You realize you might as well be calm and cool about it because if you get uptight, then everybody else becomes very nervous and hostile. The whole atmosphere in the theater deteriorates and your patient starts behind the eight ball. You start behind the eight ball. If I know that the situation is going to drag on, I will go to my office, have a coffee, then come back in. Often times I'll just sit in a corner of the room and watch the people scurrying back and forth. I try to deflate myself. (elite neurosurgeon)


Distraction Control in a Lull

Surgeons' concentration is often interrupted by lulls in the procedure. Of all the distractions in surgery, the one most commonly mentioned (94%) was delays or lulls. Typically, surgeons try to prevent frustration during lulls by relaxing, by taking a break, and sometimes by leaving the room.

Typically, if I am waiting for that x-ray to come back, and we have nothing to do, I will walk off by myself, sit down, and not talk to anybody I just want the mental break. I want to be able to think on my own about the case. It's funny You don't think about how you do these things, but I do them on a regular basis without really realizing it (orthopedic surgeon)

To remain alert during long hours of surgery requires a positive mindset, persistence, and good strategies for staying on track.

You do drift It's human nature, but that's when the risk factor increases. Of course, your attention span is decent the first hour or two, then it gradually decreases. I think the peak is between an hour and four hours. After four hours your attention span starts to lessen... You have to be aware of your attention span. As the operation gets lengthy, you have to be careful that you don't start losing your patience because you want to finish. You have to say to yourself, "No, I should not rush. I should take my time." You have to tell yourself and remind yourself that when you start to rush you get into trouble... You say, "I should slow down because it's better for the patient and it's better for me." In the long run, it will save you time and stress.. At the end of an operation, you do not want to get into trouble. That's when you want things to go smooth, so that you can finish, close, and go home. Knowing these things helps you in your preparation for those moments. (elite neurosurgeon)

If you didn't plan for how tedious it was going to be, when you get in there after about an hour you say "Holy schmoly I'm going to be in here for a day 'til the cows come home. Maybe we made a bad decision in going ahead with this. Maybe I should have planned this in stages." You go through these second thoughts even though you're already well on your way in the operation. You discipline yourself to just go at it You discipline yourself not to start taking short cuts to try to hurry it along. Usually if you just remain meticulous, stick to your guns and stick to the basic strategy you've developed you'll find that it all works out in the long run. Then you feel really good about it.,. Your resident or your assistants are also having second thoughts throughout the whole case saying, "Why the hell are we here? Is this ever going to finish? Why doesn't the silly bugger stop, get out, and come back another day?" Then all of a sudden, "Geez, it's all over and done with. Yeah, that wasn't so bad. Good thing we stuck to it and just went on with it." (elite neurosurgeon)


Constructive Evaluation

All surgeons had developed constructive procedures for evaluating their surgical performance. Evaluations generally took place after surgery, during the patient's recovery period, at morbidity and mortality rounds, and/or at a patient follow-up. Self-evaluation was viewed as very important, whether it was assessing results, visualizing to recall the procedure, or referencing notes and photographs. Consultation with patients, colleagues, and the team was also mentioned as a means of evaluation, but to a lesser degree. The very best surgeons clearly had developed persistent, ongoing procedures to evaluate and draw the lessons out of their performances.

My evaluation is simple-results. Most of it has to do with your performance, and what you've done to prepare. In particular; it's your judgment in indicating the surgery and your judgment during the operation. That judges your skill. If you've done things in the right fashion, the result is good. (elite neurosurgeon)

I always do a postmortem in my own mind on my performance ...not in any particular setting. You don't go back to your office and deliberately think about it, but it's on your mind for a little while afterwards. Sometimes you actually replay the whole operation in your mind. You replay it just like a video and say "Did I really do it the way I should have done it? Could I have done it differently?" There's a lot of replay that goes on... You actually see yourself. You almost feel it as you're doing it. (general surgeon)

You're continually trying to improve upon little things that you do just to make the whole thing smoother; quicker, and more efficient.. . I'm continually trying to improve. That's how I evaluate it (elite orthopedic surgeon)

The most critical evaluator of my performance is my patient That evaluation is usually done through discussion and examination. It's a gradual process during the postoperative period.. - The other aspect of evaluation is self evaluation and the evaluation by my peers, my colleagues, both surgical and non-surgical colleagues... It's a multidisciplinary thing, but I maintain that the critical evaluation is by the patient and the patient's family, You operate on the patient, but you treat the whole family (elite neurosurgeon)

If I have a very unusual case or something quite trying, my buddy and I often talk to each other...He comes over to my house usually once a week. He brings films over or we go to the hospital together and we talk about it, or we call each other... We try it out on each other; You can talk to anybody, if it's just a straightforward case that looks difficult or you're just wondering what approach you shou!d use. But if you're concerned with outcome, or whether you should be tackling it, you have to talk to somebody you know You have to have "a brother; "...We're like one famlly. Our first 10 years of practice we almost lived together. We just talked about everything, every case. Every time we'd have a disaster, we'd be on the phone to each other; Maybe that is preparation and evaluation. What you're doing is you're dumping your soul, then you feel better and you do it again. Otherwise you might be shy to "get back on." (neurosurgeon)

A high level of commitment to performance evaluation was not evident for all surgeons-but it was for all elite surgeons. Assessing performance outcomes is sometimes a difficult process. Somethimes the results are not clear for several months, at which time the specific procedures or techniques used may no longer be clearly remebered. A number of nonelite surgeons did not partake in high-quality, ongoing personal performance evaluations, some due to time factors, difficulties in assessing performance, or the priority given to evaluations.

A lot of times the results are months down the road in terms of complications or occurrences. I don't have a self-evaluation in the OR. When I see a patient several months down the line, sometimes I don't remember a whole lot about the surgical techniques or anything specific about what I did. (orthopedic surgeon)

The unfortunate thing I don't do is write down what my comments are. You tend to forget unpleasant things and remember the pleasant things. I wonder if it would be of any value just to write it down would be no good because you'd almost have to have the x-ray there, and that's hard. It would be too long a story. Let's face it, we're not paid to be writers. (neurosurgeon)



The top surgeons made it clear that surgeons perform at an exceptional level largely because of the quality of their mental skills, and suggested that mental skills might be more important than technical skills in surgical performance. Orlick's seven elements of excellence were clearly evident in the elite surgeons. The value of commitment, belief, positive images, mental readiness, full focus, distraction control, and constructive evaluation was discussed by these exceptional surgeons, lending support to the relevance of the "Wheel of Excellence" framework. Elite surgeons have developed excellent mental strategies for meeting difficult challenges successfully and for performing consistently at a high level.

One comment by an elite surgeon, echoed by many of the participants in the study, suggests two implications of this research:

This is the first time that I've really analyzed certain aspects of mental readiness. We have looked at aspects of complications... how to stay out of trouble and avoid problems... but we have never sat down and looked at mental preparation. We certainly prepare to do the technical aspect of the case. I don't think we prepare well enough mentally

Mental training programs that combine the experience of great surgeons and lessons from other high-performance disciplines could greatly benefit residents and young surgeons by guiding their pursuit of personal excellence. Like most performance domains medical schools teach theoretical and technical skills but rarely teach and nurture the mental skills required for excellence. Many of the great surgeons in this study reported that this was the first time they had asked to share details on their process of mental preparation and its impact of their performance. The fact that these outstanding surgeons had never been asked about these important issues suggests a need for researchers to further tap into the knowledge of exceptional performers and share that wisdom with others.



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