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date: 16 August 2018

Surgical Performance From a Psychological Perspective

Summary and Keywords

At first glance, there are certain similarities between performance in surgery and that in competitive sports. Clearly, both require exceptional gross and fine motor ability and effective concentration skills, and both are routinely performed in dynamic environments, often under time constraints. On closer inspection, however, crucial differences emerge between these skilled domains. For example, surgery does not involve directly antagonistic opponents competing for victory. Nevertheless, analogies between surgery and sport have contributed to an upsurge of research interest in the psychological processes that underlie expertise in surgical performance. Of these processes, perhaps the most frequently investigated in recent years is that of motor imagery (MI) or the cognitive simulation skill that enables us to rehearse actions in our imagination without engaging in the physical movements involved. Research on motor imagery training (MIT; also called motor imagery practice, MIP) has important theoretical and practical implications. Specifically, at a theoretical level, hundreds of experimental studies in psychology have demonstrated the efficacy of MIT/MIP in improving skill learning and skilled performance in a variety of fields such as sport and music. The most widely accepted explanation of these effects comes from “simulation theory,” which postulates that executed and imagined actions share some common neural circuits and cognitive mechanisms. Put simply, imagining a skill activates some of the brain areas and neural circuits that are involved in its actual execution. Accordingly, systematic engagement in MI appears to “prime” the brain for optimal skilled performance. At the practical level, as surgical instruction has moved largely from an apprenticeship model (the so-called see one, do one, teach one approach) to one based on simulation technology and practice (e.g., the use of virtual reality equipment), there has been a corresponding growth of interest in the potential of cognitive training techniques (e.g., MIT/MIP) to improve and augment surgical skills and performance. Although these cognitive training techniques suffer both from certain conceptual confusion (e.g., with regard to the clarity of key terms) and inadequate empirical validation, they offer considerable promise in the quest for a cost-effective supplementary training tool in surgical education. Against this background, it is important for researchers and practitioners alike to explore the cognitive psychological factors (such as motor imagery) that underlie surgical skill learning and performance.

Keywords: surgical performance, psychology, motor imagery, motor imagery training/practice, cognitive training, simulation

Introduction

Recent years have witnessed an upsurge of research interest, both in psychology and medicine, in the “cognitive” (i.e., mental factors involved in thinking about or knowing something) aspects of surgical training and performance. According to Wallace et al. (2017), this trend reflects a general shift in surgical education away from traditional training methods (which focused mainly on teaching procedural surgical motor skills) and toward an approach involving “cognitive training.” This latter term refers to the use of instructional programs designed to enhance specific cognitive processes (e.g., “mental imagery” or the cognitive simulation skill that enables us to create virtual experiences of things that are not physically present or happening right now; Moran, Guillot, MacIntyre, & Collet, 2012) that are known to promote surgical proficiency (e.g., see Arora et al., 2011a).

The growing importance of research on cognitive processes in surgery is evident both in the scientific literature and in the popular press. To illustrate the former, there has been an abundance of recent studies on cognitive topics in the surgical research literature. Among the topics addressed in this regard are “expertise” (defined as the study of what makes people exceptionally knowledgeable about or skilled in a particular field; see Silvennoinen, Mecklin, Saariluoma, & Antikainen, 2009); “cognitive load” (defined as the mental demands placed on people’s working memory; see Haji, Rojas, Childs, de Ribaupierre, & Dubrowski, 2015), and “motor imagery” (defined as a type of mental imagery that involves “mentally simulating an intended action without actually producing it”; Smith & Kosslyn, 2007, p. 456). Complementing such research at the popular level, Lagnado (2016) investigated for the Wall Street Journal some intriguing strategies used by surgeons to maintain their concentration while working in the operating room over long periods of time (e.g., 8–10 hours when transplanting a liver).

A key impetus for studies on cognitive aspects of surgery is the proposition that surgery is a “performance science” (Kneebone, 2016) that has many commonalities with other highly fields of highly skilled human activity such as elite sport (Sevdalis, Moran, & Arora, 2013). At first glance, this analogy is persuasive. For example, both successful surgical and competitive athletic performance require significant gross and fine motor ability and effective concentration skills. In addition, both types of skilled endeavors are routinely performed under considerable pressure in dynamic environments that can change rapidly. Of course, such similarities should not blind us to the fact that there are important differences between the domains of sport and surgery. For example, surgeons do not compete against each other as antagonistic opponents in pursuit of victory. Nevertheless, recognition of parallels between surgery and elite sport, combined with increased interest in the mental processes of surgeons, have prompted researchers (e.g., Wallace et al., 2017) to evaluate the effects of cognitive enhancement techniques on surgical performance. Building on such research, this article reviews key recent studies (i.e., those conducted in the last five years) on one cognitive technique used in surgical education—namely, motor imagery training (MIT; also known as “motor imagery practice,” MIP) or the “cognitive rehearsal of a task in the absence of overt physical movement” (Driskell, Copper, & Moran, 1994, p. 481). An in-depth evaluation of MIT/MIP is timely for two reasons. On the one hand, based on searches of a psychological research databases (PsycINFO), MIT/MIP is probably the most popular form of cognitive enhancement technique used in surgical education over the past decade. On the other hand, at a practical level, it is widely employed by experienced surgeons. To illustrate, McDonald, Orlick, and Letts (1995) reported that 73% of their sample of experienced surgeons used imagery to rehearse their skills prior to carrying out surgical operations.

The article is organized in three parts as follows. The first section examines the nature, terminology, and theoretical basis of motor imagery training/practice. The next section contains a brief integrative summary of some key experimental studies conducted between 2012 and 2016 that evaluated MIT/MIP programs in surgical training (for a review of earlier research on this topic, see Sevdalis et al., 2013). The final section sketches some conclusions about, and new directions for, research on imagery training in surgery.

Motor Imagery Training/Practice: Nature, Terminology, and Theoretical Mechanisms

One of our most compelling mental skills is the ability to use our imagination to mimic or simulate perceptual (e.g., “seeing” a red traffic light in one’s mind’s eye) and motor (e.g., kicking a ball) experiences. In psychology, the term “mental imagery” refers to a “multimodal” (i.e., involving different sensory systems) cognitive simulation process that enables us to represent perceptual information in our minds in the absence of actual sensory input (Munzert, Lorey, & Zentgraf, 2009). Technically, it involves the “voluntary retrieval and representation of sensory information from memory” (Pearson, 2014, p. 178) in the absence of a direct external stimulus. In other words, imagery enables us to create virtual experiences of sights, sounds, and perceptions of things that are neither present in our environment nor actually happening to us at that moment (Moran & Toner, 2017). For example, if you close your eyes for a moment you can probably “see” a red traffic light in your mind’s eye and “hear” the sound of an ambulance siren in your mind’s ear—even though you are not standing beside a road right now. Here, the “sight” that you see and the “sound” that you “hear” comes from your memory of traffic lights and ambulance sirens that you have experienced in the past, not from actually perceiving them. Similarly, our imagination can simulate perceptual experiences in other senses. For instance, you may be able to “smell” a freshly peeled orange or to “taste” a cup of strong coffee in the absence of these stimuli. Furthermore, turning to bodily processes, you should be able to imagine physical sensations like clenching your fist or stretching both arms high above your head as if you were trying to touch the ceiling. It is this latter experience of imaginary bodily movements that characterizes motor imagery or the mental simulation of an action without actually executing it (see Hanakawa, 2016).

As explained in the introduction, motor imagery training/practice involves the systematic use of imagery to mentally perceive and to rehearse covertly a movement in one’s imagination without actually executing it. Historically, this process of simulating actions imaginatively has been studied in psychology under a variety of terms including “mental practice” (Vandell, Davis, & Clugston, 1943), “implicit practice” (Morrisett, 1956), “covert rehearsal” (Corbin, 1967), “mental training” (Jeannerod, 1997), “motor imagery training” (Mizuguchi et al., 2013), and “motor imagery practice” (Di Rienzo et al., 2016). Unfortunately, this profusion of terminology has generated semantic confusion and hampered interpretation and integration of research finding in the field. For example, some “mental practice” training programs have included non-imagery techniques such as “psyching-up” strategies, relaxation methods, and self-efficacy affirmation statements. In the interest of clarity, therefore, the present article will restrict the term “motor imagery training/motor imagery practice” (MIT/MIP) to cognitive training interventions in which the procedure required to perform a targeted task or skill is imagined (i.e., mentally simulated in the absence of actual physical movement).

Historically, psychological interest in motor imagery is as old as the discipline of psychology itself. To illustrate, the covert simulation of physical actions was considered by James (1890) in his prescient discussion of “motor images” (p. 708). Indeed, he suggested rather counterintuitively that by anticipating experiences imaginatively, people actually learn to skate in the summer and to swim in the winter! Interestingly, the 1890s also witnessed various expressions of an intriguing idea called the “ideo-motor principle,” which postulated that all thoughts have muscular concomitants (see Stock & Stock, 2004, for a detailed account of this proposal). Thus, in 1899 Henri-Etienne Beaunis (cited in Washburn, 1916) proposed that “it is well known that the idea of a movement suffices to produce the movement or make it tend to be produced” (p. 138). Around the same time, Carpenter (1894) proposed that imagined movement may elicit similar nervous activity to that activated during actual movement. Complementing such propositions, Anderson (1899) conducted a series of studies demonstrating the effects of motor imagery training on gymnastic skills. He concluded that gymnastic movements could be learned without actual use of the muscles, solely through mental rehearsal. Since the 1890s, hundreds of experimental studies have demonstrated the efficacy of MIT/MIP in improving skill learning in a variety of domains such as sport (e.g., Olsson, Jonsson, Larsson, & Nyberg, 2008), music (Bernardi De Buglio, Trimarchi, Chielli, & Bricolo, 2013), and clinical surgery (Arora et al., 2011a, 2011b).

The typical experimental paradigm used to study MIT/MIP effects involves the comparison of the pre- and post-intervention performance of four groups of participants: those who have been engaged only in physical practice of the skill in question (the physical practice group, PP); those who have mentally practiced it (the mental practice group, MP); those who have alternated between physical and mental practice (PP/MP); and, finally, participants in a non-practice control condition (Driskell et al., 1994). After a pre-treatment baseline test has been conducted on a designated skill, participants are randomly assigned to one of these conditions (PP, MP, PP/MP, or control). Normally, the cognitive rehearsal that occurs in the MP treatment condition is guided by a mental imagery “script” that describes the motor actions to be executed in clear and vivid detail (see Arora et al., 2010; and Williams, Cooley, Newell, Weibull, & Cumming, 2013, for surgical and sporting examples, respectively). Ideally, this script should contain a list of procedural steps to be rehearsed before executing the skill as well as various cues designed to enhance the representation of this skill in the participant’s mind. After this MIT/MIP intervention has been applied, the participants’ performance on the target skill is tested again. If the performance of the MP group is significantly superior to that of the control group, then a positive effect of mental practice is deemed to have occurred. Strictly speaking, according to Driskell et al. (1994), inferences about positive effects of MIT/MIP training should be confined to studies in which the performance of participants engaging in mental practice is compared with that of participants in the control (no practice) condition. However, reports of MIT/MIP effects have occurred in studies (e.g., see Malouin, Richards, Doyon, Desrosiers, & Belleville, 2004) in which the motor imagery manipulation is a composite of mental and physical practice.

Based on the preceding experimental paradigm, a number of general conclusions about mental practice have emerged in the literature. First, relative to not practicing at all, MIT/MIP appears to improve skilled performance. However, mental rehearsal is less effective than is physical practice. More precisely, a meta-analytic review by Driskell et al. (1994) showed that physical practice (PP) treatment conditions produced greater statistical effect sizes than was evident in motor imagery training conditions. Secondly, MIT/MIP, when combined and alternated with physical practice, seems to produce superior skill learning to that resulting from either mental or physical practice conducted alone. Thirdly, research suggests that motor imagery training improves the performance of cognitive skills (i.e., those that involve sequential processing activities; e.g., mirror drawing tasks) more than it does for motor skills. Fourthly, there seems to be an interaction between the level of expertise of the performer and the type of task that yields the best improvement from mental rehearsal. Specifically, expert performers tend to benefit more from motor imagery training than do novices, regardless of the type of skill being practiced (either cognitive or physical).

What theoretical mechanisms account for such effects? Perhaps the most widely accepted theoretical account of how motor imagery training works is that provided by Jeannerod’s (1994, 2001, 2006) simulation theory. Although space limitations preclude a detailed account of this approach (for a comprehensive account, see O’Shea & Moran, 2017), its central tenets may be summarized as follows. To begin with, it postulates that action planning and motor imagery share a common mental representation. In other words, motor imagery is based on the motor representation that underlies actual motor performance. Interestingly, James (1890) had anticipated this idea when he speculated that “sensation and imagination are due to the activity of the same centres in the cortex” (p. 720). Next, simulation theory proposes that the motor system is part of a cognitive network that includes other psychological activities such as imagining actions, learning by observation, and attempting to understand the behavior of other people. Third, Jeannerod (2001) claimed that actions involve a covert stage during which they are prepared or simulated mentally. This covert stage involves “a representation of the future, which includes the goal of the action, the means to reach it, and its consequences on the organism and the external world. Covert and overt stages thus represent a continuum, such that every overtly executed action implies the existence of a covert stage” (p. S103). Finally, combining these propositions, Jeannerod (2001) postulated that “motor imagery . . . should involve, in the subject’s motor brain, neural mechanisms similar to those operating during the real action” (pp. S103–S104)—the so-called functional equivalence hypothesis. According to this hypothesis, imagined and executed actions share, to some degree, certain mental representations and underlying mechanisms (see brief review in Moran et al., 2012). For example, both overt and imagined actions share a motor representation of an intention to act. Whereas this intention is converted into an actual physical movement in the case of overt actions, it is inhibited in the case of imagined actions. Nevertheless, this shared motor representation facilitates certain forms of functional equivalence between actual and imagined actions. Thus, Hétu et al. (2013) found that the neural network underlying motor imagery includes several cortical regions known to control actual motor execution. Furthermore, Debarnot, Sperduti, Di Rienzo, and Guillot (2014) concluded that the brain changes that occur during mental practice of a given motor skill tend to mimic closely those that occur after physical practice of the same skill. More recently, Avanzino et al. (2015) found that motor imagery training induces neuroplasticity in the motor cortex.

Complementing the preceding neuroscientific findings, there is also evidence of functional equivalence between imagined and actual motor processes at a behavioral level. The logic here is as follows. If imagined and executed actions rely on similar motor representations and activate some common brain areas, then their temporal organization should be equivalent. Accordingly, there should be a close correspondence between the time required to mentally perform a given action and that required for its actual execution. Support for this idea comes from studies using “mental chronometry” tasks that involve evaluating the correspondence between the actual and imagined duration required to perform a given action (see review by Guillot & Collet, 2005). Building on simulation theory, Ridderinkhof and Brass (2015) developed an account of motor imagery called “predictive-processing theory.” This theory postulates that motor imagery works through an internal emulation process involving the anticipation of action effects. This emulation mechanism seems to be implemented in brain regions that partially overlap with those regulating overt motor behavior (e.g., the cerebellum, basal ganglia). According to Ridderinkhof and Brass (2015), the motor representation triggers an internal “emulation” process of the planned motor act that has a high degree of similarity to the actual motor output. The comparison of the anticipated action effect and the internal emulation of the motor act provides an error signal that forms the basis for improving motor performance—even if the actual movement is inhibited (i.e., does not occur). In summary, there are close parallels between the neurocognitive mechanisms underlying motor imagery and motor execution.

Motor Imagery Training/Practice and Surgical Performance

The purpose of this section is to provide a brief critical synthesis of some recent studies on the efficacy of motor imagery training in improving surgical performance. In their earlier review of this topic, Sevdalis et al. (2013) identified and evaluated a total of 13 experimental studies on motor imagery training in surgery that had been published between 1994 and 2011. A number of these studies found positive effects of imagery training on surgical performance. For example, Arora et al. (Arora et al., 2011a, 2011b) demonstrated that an empirically validated motor imagery intervention that had been delivered to groups of surgical novices led both to significant improvements in their technical performance and to significant reductions in their stress levels in comparison with those of peers in control groups. More precisely, Arora et al. (2011a) discovered that imagery-trained novice laparoscopic surgeons performed significantly better than counterparts in control conditions (who had viewed online lectures as training) on five virtual-reality laparoscopic cholecystectomies. Unfortunately, other studies in the review were marred by methodological shortcomings that hamper accurate interpretation of the results reported. Among these weaknesses were the use of idiosyncratic, unvalidated MP intervention scripts/protocols; inadequate checks on the degree to which participants had complied with imagery instructions; and the failure by investigators either to measure or to control for individual differences in imagery ability among participants. Despite their reservations about such problems, Sevdalis et al. (2013) concluded in their review that where motor imagery training “has been delivered in a reasonably robust manner, it has enhanced the technical (psychomotor) performance of (typically junior) surgeons” (p. 357). Furthermore, these authors concluded from qualitative studies of senior surgeons as well as junior peers that motor imagery training is an important determinant of surgical performance excellence.

For our purposes here, and in an effort to update the review by Sevdalis et al. (2013), we used the MEDLINE and PsycINFO databases to identify eight further papers published between 2012 and 2016 on motor imagery training/practice in surgery (see Table 1).

Table 1. Recent (2012–2016) Research on Effects of Motor Imagery Training/Practice (MIT/MIP) on Surgical Performance

Authors

Surgical Speciality and Participant Status

Design and Methodology

Key Findings

Geoffrion et al. (2012)

  • Gynecological surgery

  • 50 novice surgical trainees

  • Experimental, randomized controlled design (2 groups of 25 Ss each): textbook reading (control) vs. MIT/MIP training

  • Assessed pre- and post-intervention

  • Global and procedure-specific performance assessed; Ss’ self-assessment scores collected

  • Ad hoc developed MIT/MIP protocol

  • MIT/MIP participants showed no improvement in performance

  • MIT/MIP participants scored significantly higher on performance self-assessments

Mulla et al. (2012)

  • Basic laparoscopic skills

  • 41 medical students

  • Simulation setting

  • Experimental, randomized controlled design (5 groups of 8–9 Ss each):

    • No training (control)

    • Trained on laparoscopic box trainer (BT)

    • Trained on BT with an additional practice session

    • Trained on a laparoscopic virtual reality simulator (VRS)

    • Trained with mental practice (MIT/MIP)

  • Assessed for time, precision, accuracy, and performance

  • Ad hoc developed MIT/MIP protocol

  • MIT/MIP gave no benefits over other forms of training, or in some cases, demonstrated no improvements over the no training control group

Patel et al. (2012)

  • Open/endovascular arterial surgery

  • Vascular surgeons

  • Over 6 weeks, 15 open and endovascular combined procedures evaluated

  • After 9 procedures, MIT/MIP implemented prior to endovascular phase of procedures

  • Pre- and post-intervention error rates were compared

  • Ad hoc developed MP protocol

  • MIT/MIP resulted in significantly lower error rates, and significantly lower “danger” and “delay”scores

Eldred-Evans et al. (2013)

  • Basic laparoscopic skills

  • 64 medical students

  • Simulation setting

  • Experimental, randomised controlled design (4 groups of 16 Ss each):

    • Trained on box trainer (BT)

    • Trained on BT with added VRS training

    • Trained on BT with added MIT/MIP training

    • Trained on VRS with added MP training

  • Assessed for time, precision, accuracy, and overall performance

  • MIT/MIP protocol based on theoretical model of mental practice

  • “BT with MIT/MIP” participants improved significantly more from baseline to follow-up on both BT and VRS assessments

  • “VRS with MIT/MIP” participants demonstrated the worst performance on both assessments

Louridas et al. (2015)

  • Advanced laparoscopic skills (bariatric surgery)

  • 20 senior surgical trainees

  • Simulation setting

  • Experimental, randomized controlled design (2 groups of 10 Ss each): control training vs. MIT/MIP training

  • Assessed pre- and post-intervention

  • Technical skills, nontechnical skills, and stress parameters measured

  • Ad hoc developed MIT/MIP protocol

  • MIQ used to assess mental imagery ability

  • MIT/MIP participants improved significantly more between base line and follow up, in technical skills and mental imagery ability

Paige et al. (2015)

  • Basic laparoscopic skills

  • 19 novice surgical trainees

  • Simulation setting

  • Experimental, randomized controlled design (2 groups of 9–10 Ss each): simulation based procedure-specific training vs. VRS training

  • Assessed pre-and post-intervention

  • Virtual reality objective measures and procedural task performance assessed

  • Ad hoc developed MIT/MIP protocol

  • MIQ used to assess mental imagery ability

  • MIT/MIP participants improved significantly more between base line and follow up, in confidence, visual imagery, and knowledge

  • Positive correlation between MIQ score improvements and improving time and performance scores

Chadha et al. (2016)

  • Microsurgery

  • 36 surgeons recruited from a microsurgery skills course

  • Simulation setting

  • Experimental, randomized controlled design (3 groups of 12 Ss each):

    • Control group with no MIT/MIP script

    • MR group, given a procedural MIT/MIP script

    • Relaxation group, given a relaxation script unrelated to procedure

  • Performance assessed daily throughout the course

  • Ad hoc developed MIT/MIP protocol

  • MIT/MIP participants improved significantly more in performance, on day 4 post-intervention

  • MIT/MIP participants improved significantly more in dexterity, visual-spatial skills, and operative flow

Yiasemidouet al. (2016)

  • General surgery

  • 15 novice surgical trainees

  • Pilot study

  • Simulation setting

  • Experimental, randomized controlled design (2 groups): didactic video-based training (10 Ss) vs. structured MIT/MIP training with interactive 3D visual aid (5 Ss)

  • Performance and safety variables assessed

  • Ad hoc developed MI/MP protocol

  • MIT/MIP participants performed the task with significantly fewer total number of movements, significantly shorter total path length, and significantly faster

Note: abbreviations as follows: BT=box trainer; MIQ=Mental Imagery Questionnaire; MIT/MIP=motor imagery training/practice; Ss=research subjects; VRS=virtual reality simulator.

Inspection of these studies reveals at least four general trends in the evidence. First of all, Table 1 shows that a variety of surgical procedures/skills have been targeted for imagery training. These skills include gynecological (Geoffrion et al., 2012), laparoscopic (Eldfred-Evans et al., 2013; Louridas, Bonrath, Sinclair, Dedy, & Grantcharov, 2015; Mulla et al., 2012; Paige, Yu, Hunt, Marr, & Stuke, 2015; Yiasemidou et al., 2016), endovascular (Patel et al., 2012) and microsurgical (Chadha, Hachach-Haram, Shurey, & Mohanna, 2016) procedures or tasks. Across these studies, surgical performance was typically assessed using simulators (i.e., rather than being assessed in real clinical surgery). Second, most of the studies used experimental research designs involving randomized trials with control groups. Third, in line with what Sevdalis, Moran, and Arora (2013) discovered in their review, the studies in Table 1 vary considerably in the extent and precision of the information that they provide concerning the imagery training protocols that they used. On the positive side, Louridas et al. (2015) explained the theoretical rationale for, and development of, their imagery script in some detail. Conversely, the adequacy of the information on imagery protocols provided by Mulla et al. (2012) and Patel et al. (2012) is questionable. Although this weakness may be due to limitations in reporting (hampered by typically short in length clinical articles) rather than in the development/implementation of the protocols, it poses a major challenge for the task of evaluating available evidence on the quality (including intensity or fidelity) of delivery of motor imagery training and the associated efficacy of such training. Additional methodological problems stem from the fact that few of the studies in Table 1 appear to have included “manipulation checks” in order to ensure that participants in the experimental group (i.e., those who received imagery training) actually complied with their imagery instructions—and that those counterparts in the control group (i.e., no imagery training condition) did not engage in covert mental rehearsal, or at least that the mental imagery of the trained participants was in some systematically assessed or theory-driven manner richer than that of their control peers. In the absence of such experimental precautions, questions arise as to the validity of the inferences drawn from the data analysis. This problem was acknowledged by Geoffrion et al. (2012) who admitted that “MI instructions at different centres many have provided heterogeneous training” (p. 5; a fidelity issue) and that “control residents may have been performing MI unknowingly while reading the assigned textbook chapters” (p. 5; a contamination issue). The fourth conclusion is that despite their methodological weaknesses, the studies in Table 1 suggest broadly that motor imagery training can be beneficial to surgical performance. More precisely, six of the eight studies (Chadha et al., 2016; Eldred-Evans et al., 2013; Louridas et al., 2015; Paige et al., 2015; Patel et al., 2012; Yiasemidou et al., 2016) claimed that imagery training tends to improve surgical performance; improve trainees’ confidence; and reduce trainee errors relative to performance in control and/or baseline conditions. In summary, despite certain methodological limitations, recent studies on motor imagery training in surgery offer conclusions that are broadly consistent with those evaluated by Sevdalis et al. (2013). Overall, these conclusions suggest that motor imagery offers a potentially effective performance-enhancement technique in surgical training.

Conclusions and New Directions

The present review suggests that cognitive psychological aspects of surgical performance—especially those concerning motor imagery training/practice—offer a fertile domain for researchers and clinicians alike. Academically, research on mental imagery in surgery provides unique opportunities for the development and empirical testing of theories about the mechanisms underlying MP effects (for a review of such mechanisms, see O’Shea & Moran, 2017). In particular, the domains of surgical training and surgical performance provide a dynamic natural laboratory in which to investigate the postulates of motor simulation theory. Augmenting such possibilities, applied scientists can contribute to the topic by comparing and contrasting MP efficacy across different skill types and levels of performer expertise. Clinically, further investigation of imagery effects within the field of surgery offer a promise to enhance surgical performance and thus indirectly patient safety through utilization of a resource available to all surgeons at all times—their own mental imagery. For these advances to be achieved, we propose a serious effort to produce a repository or library of validated motor imagery training protocols for various surgical procedures, as well as the use of validated and theory-driven imagery protocols and imagery assessments for use in research and training (cf. Sevdalis et al., 2013). We believe that mental imagery can yield significant societal benefits if soundly studied and consistently applied across areas of human skilled performance, such as clinical surgery.

Funding Acknowledgments

Sevdalis’s research is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London at King’s College Hospital NHS Foundation Trust. Sevdalis is a member of King’s Improvement Science, which is part of the NIHR CLAHRC South London and comprises a specialist team of improvement scientists and senior researchers based at King’s College London. Its work is funded by King’s Health Partners (Guy’s and St Thomas’s NHS Foundation Trust, King’s College Hospital NHS Foundation Trust, King’s College London and South London and Maudsley NHS Foundation Trust), Guy’s and St Thomas’s charity, the Maudsley Charity and the Health Foundation. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.

Conflicts of Interest

Sevdalis is the director of London Safety and Training Solution Ltd, which provides team and safety interventions, assessment, and training to hospitals in the United Kingdom and internationally on a consultancy basis.

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