Enhancing surgical performance by adopting expert musicians' practice and performance strategies

ARTICLE IN PRESS Surgery ■■ (2017) ■■–■■

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Surgery j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y m s y

Enhancing surgical performance by adopting expert musicians’ practice and performance strategies Mei Rui, DMA, Jeffrey E. Lee, MD, Jean-Nicolas Vauthey, MD, and Claudius Conrad, MD, PhD * Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

A R T I C L E

I N F O

Article history: Accepted 25 September 2017

A B S T R A C T

Background. Surgery is a performing art—each surgical procedure is a live performance that has immediate and irreversible consequences for both the performer and the audience. Surgeons operate with surgical instruments, whereas musicians perform with musical instruments. Both perform in highstress, high-risk work environments, where small errors in motor performance or judgment can have immediate negative consequences. While there is abundant literature on musical performance and their impact on outcome, little similar research has been published in the field of surgery. We aimed at identifying expert musicians’ practice and performance strategies that may aid surgeons to enhance their surgical performance. Methods. In the study, 82 relevant English-language articles from 1974 to 2017 matched applicable search terms. Nominal Group Technique was applied to identify 5 key domains that comprise important parallels between surgical and expert musical performance. Results. The 5 key domains identified were: (1) extensive training and deliberate practice, (2) dexterity and ambidexterity, (3) performance evaluation and competition, (4) performance-related injuries, and (5) performance anxiety. We found focused and mindful training in motor performance, not performing immediately after a hiatus from practice, training to improve the precision and responsiveness of the nondominant hand, continuous and critical self-evaluation, training in injury recognition and prevention, and pharmacologic factors to be of utmost importance. Conclusion. Critical parallels exist between surgical and expert musical performance that may improve surgical outcomes by adopting musicians’ strategies for combating physiological and psychologic performance-related issues. Raising surgeons’ awareness for this subject content may improve surgical performance and patient outcomes, as well as help prevent occupational injuries. (Surgery 2017;160:XXX-XXX.) © 2017 Elsevier Inc. All rights reserved.

Surgeons operate with surgical instruments, whereas musicians perform with musical instruments. Historically, there have been several eminent surgeon-musicians, including Herman Boerhaave (1668–1738), Leopold Auenbrugger (1722–1809), Theodore Billroth (1829–1894), Alexander Borodin (1833–1887), Albert Schweitzer (1875–1965), and Boyd Neel (1905–1981), each of whom made landmark contributions to surgical science and humanity. It seems intuitive that the ability of these surgeon-musicians to play an instrument likely enhanced their motor performance to facilitate their expert surgical performance.

The University of Texas MD Anderson Cancer Center is supported in part by the National Institutes of Health/National Cancer Institute under award number P30CA016672. All authors claim no conflicts of interest or disclosures. * Corresponding author. MD Anderson Cancer Center, Division of Surgery, Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas, 1400 Pressler, Unit 1484, FCT17.5046, Houston, TX 77030, USA. E-mail address: [email protected] (C. Conrad).

However, while parallels between surgical and expert musical performance exist, there is a dearth of literature on how surgeons could potentially adopt expert musicians’ practice and performance strategies to improve surgical performance. We therefore performed a structured analysis of the published literature on musicians’ practice and performance strategies that could help surgeons to improve their motor performance in the operating room, improve mental health and prevent musculoskeletal injuries. Methods PubMed was searched for English-language articles published between 1974 and 2017 using the search terms “surgical performance,” “surgical skill,” “surgeon hand dominance,” “surgeon dexterity,” “manual ambidexterity,” “pianist dexterity,” “musician deliberate practice,” “competition performance,” “musician musculoskeletal health,” “surgeon musculoskeletal health,” “musician hand injury,” “surgeon hand injury,” “musician performance anxiety,” “surgeon performance anxiety,” “performance stage fright,” “surgical

https://doi.org/10.1016/j.surg.2017.09.011 0039-6060/© 2017 Elsevier Inc. All rights reserved.

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Fig. Parallels between surgical and musical performance.

performance propranolol,” “musicians propranolol,” and other combinations of relevant terms. The reference lists of articles identified in the searches were cross-reviewed by authors to identify additional relevant articles. Then the authors reviewed the identified articles independently to (1) identify relevant articles, (2) extract key parallels between surgical and musical performance, and (3) collaboratively evaluate the information for relevance. Nominal Group Technique to take each group member’s opinion into account was applied. First, group members reviewed the literature independently and provided a list of key domains with their supporting relevant literature. Duplicate musical domains were eliminated by the facilitator. The facilitator encouraged discussion for the naming and identification of domains to find the domain terms that would encompass most of the relevant literature. For example, domains such as “collaboration and team dynamics” and its parallel “chamber music” were discussed, voted to be less relevant and therefore excluded. The 5 domains with the highest ranking were selected as the 5 domains under which the relevant literature was grouped. Prioritizing the recorded domains pertaining to parallels between musical and surgical performance were performed using direct voting. Published articles on surgical performance and musical practice guidelines and performance strategies were compared. The data were synthesized to identify concrete practice and performance guidelines that could aid surgeons in improving surgical performance.

competitive fields such as surgery and classical music is required.3,6 For most surgeons, completion of surgical training requires 5 to 10 years—equivalent to ≈10,000 hours—of total-immersion training. Similarly, a graduate-level, professional pianist also will have accumulated ≈10,000 hours of practice, while an amateur one of comparable age will have practiced only 2,000 to 8,000 hours.7 A study on surgical residents showed that deliberate practice, compared with standard training alone, led to higher-quality laparoscopic surgical performance as measured by speed, dexterity, and global rating scales.8 Recently, educational initiatives have been implemented to accelerate the “training to competence” process and decrease hours spent in surgical training.9 Whether this can actually be accomplished successfully is an area of ongoing research.10,11 Furthermore, the importance of deliberate practice may extend beyond surgical trainees to staff surgeons in practice: low operative volume institutions have significantly higher 90-day mortality and lower-quality oncologic surgery for patients undergoing laparoscopic pancreaticoduodenctomy.12 Insufficient “practice time” in performing this complicated procedure is almost certainly a major factor. Among musicians, it is a well-regarded principle that consistent deliberate practice contributes to performance success, while paucity or interruption of practice has a deleterious effect on performance quality. Various studies have shown that productivity is reduced when the temporal distance between tasks increases.13,14 In 188 surgeons who performed 56,315 coronary artery bypass grafting surgeries, each additional day away from the operating room increased the inpatient’s mortality rate. Among the subgroup of emergent patients treated by high-volume providers an additional day away raised mortality risk by 0.398 percentage points (11.4% relative effect). For surgeons needing to intervene in patients emergently, as temporal distance increases, the ability to recognize and address life-threatening emergent complications decreases. Absence from the operating room for 3 to 14 days before surgery raised the mortality risk by 11% to 14% (relative effect), and absence for >15 days raised the mortality risk by 22%.15 While it would be unimaginable for a concert violinist to vacation without practicing on their instrument in the days leading up to an important concert, surgeons may elect to perform challenging operations the day after returning from a trip, resulting in compromised surgical outcomes. Recommendations for surgeons

Results A total of 82 relevant articles were identified. Five parallels were identified between surgical and musical performance (Fig). To achieve optimal performance, both expert surgeons and musicians may benefit from (1) extensive training, deliberate practice, (2) ambidexterity, and continuous performance evaluation. Both are susceptible to (3) performance-related injuries, (4) performance anxiety, and may draw on (5) pharmacologic measures, especially the use of β-blockers, to alleviate symptoms. The extracted information was discussed in a structured review process and the results are presented below. After discussion of the data, each performance item is followed by concrete recommendations on how to use the information from expert musical performance to improve surgical performance. Movement I: extensive training and deliberate practice Surgical and musical performance both require extensive training and deliberate practice to achieve and maintain expertise.1-5 Deliberate practice is a mindful, structured, repetitive, and reflective process that demands relentless self-critique, and error detection. An estimated minimum of 10 years of intense involvement and 10,000 hours of deliberate practice to achieve mastery in highly

Data on deliberate practice suggest that reduction in surgical trainees’ work-hours can compromise mastery of surgical motor and patient management tasks.10,11 Therefore, to compensate for the decreased hours spent in the operating room, surgical simulation, focused training in motor performance, and earlier specialization to reduce dilution of training may be beneficial. Moreover, surgeons should consider avoiding scheduling high-risk operations immediately after returning from a surgical hiatus lasting for ≥3 days. Movement II: dexterity and ambidexterity Surgical performance and musical performance both require high levels of dexterity in both the dominant and the nondominant hand. Surgeons routinely need to use their nondominant hand to facilitate surgery—to support anatomic structures or to optimize the angle of dissection. A previous study showed that using the nondominant hand to operate required 1.45 times as long as using the dominant hand,16 suggesting an asymmetry in dexterity between the dominant and nondominant hands. Other recent studies revealed high bimanual dexterity as a predictor of expert surgical performance,17 and a trend toward improved navigation and bimanual performance with daily training of the nondominant hand using designated activities, such as playing video games.18

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Numerous studies have demonstrated the superb dexterity of musicians’ hands,19 and the greater agility in the nondominant hand compared to nonmusicians.20 From an early age pianists receive extensive bimanual training, which has been shown to even out the inherent asymmetry of the hands through technical drills consisting of etudes composed for the nondominant hand.20 Further, neurologic correlates have been associated with these physical findings: whereas nonmusician controls have a pronounced left-largerthan-right asymmetry in the intrasulcal length of the precentral gyrus, which correlates with the size of the primary motor cortex, pianists exhibit significantly more symmetry between left and right intrasulcal length of the precentral gyrus.21 The proposed mechanism for this greater symmetry in musicians is functionally induced plasticity and long-term structural adaptations in the human motor cortex as a result of extensive training. Other studies have highlighted the plasticity of the nondominant hand in both musicians and nonmusicians after amputations.22,23 After losing his right arm during World War I, the eminent pianist Paul Wittgenstein (1887–1961), to whom Ravel dedicated his Piano Concerto for the Left Hand, became a celebrated left-handed concert pianist.24 Alexander Scriabin, a right-handed pianist and composer who endured chronic right-hand pain, altered his piano compositions to adapt to the physical imbalance between is hands.25 In this context, it has been shown, that surgeons, playing a musical instrument and/or video games may improve surgical dexterity and suturing skills of the nondominant hand.26-28 The above data suggest that nondominant hand dexterity can be enhanced through extensive training. An approach frequently used in stroke patients to improve neural plasticity and motor performance involves targeting the primary motor cortices with bihemispheric noninvasive transcranial direction current stimulation (tDCS),29 a noninvasive brain-stimulating technique.30,31 Among musically untrained control subjects, tDCS improved fine motor control in both hands, especially the nondominant hand.32 More interestingly, another study demonstrated that the older the pianists started their musical training, the more they benefited from tDCS.33 Future research is needed to investigate tDCS for ambidexterityoptimization for surgeons with particularly reduced performance of their nondominant hand. While technological innovations like robotic and laparoscopic surgical platforms can help overcome innate hand dominance34 through superior ergonomics, greater magnification and improved tremor filtration, many procedures require direct manual manipulation. Due to the scarcity of data documenting the effect of handedness on surgical outcomes, investigations in this under-researched area are necessary to understand how ambidexterity may impact outcomes and how surgeons with below-average ambidexterity can be identified and trained to improve performance of their nondominant hand. Recommendations for surgeons On the basis of the aforementioned data, we recommend that surgical trainees be considered for testing for the degree of inherent asymmetry between the dexterity of the dominant and nondominant hands. Those with the largest disparity should have the opportunity to undergo task-specific training to improve the precision and responsiveness of their non-dominant hand. tDCS may be further investigated to determine whether it may improve surgical dexterity of the nondominant hand. Movement III: performance evaluation and competitions To become professional surgeons and musicians, apprentices in both fields go through numerous competitions and examinations to have their skills evaluated by experts. While musicians competing

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for an orchestral position inevitably must undergo live performance auditions, surgical trainees are commonly not evaluated for their technical or performance skills (surgical performance under pressure) when applying for a training program. Although sound has traditionally been valued as the only factor in judging performance quality in the field of music,35 studies have confirmed the critical impact of visual information on the audience’s evaluation of musical performances—a phenomenon referred to as the Colavita visual dominance effect.36 In one study, professional and novice musicians alike consistently rated silent video recordings of performances by the winners of international piano competitions more favorably than those of less successful competitors.37 Another study showed that orchestral conductors’ skills were rated accurately on the basis of the visual cues conveyed through their conductive gestures alone.38 These studies collectively suggest the importance and reliability of evaluating musical performance from visual cues only. In the field of surgery, it is intuitive that the technical aspects of surgical performance can be assessed visually. Furthermore, by watching videos of surgical performance, surgeons can not only accurately assess their peers’ laparoscopic skills, but also even estimate their peers’ risk-adjusted postsurgical complication rate.39 This suggests that videos should be more commonly utilized for evaluating surgeons’ performance. Researchers also have tested whether having a large number of reviewers judge surgical performance on the basis of videos alone (a “crowdsourcing” approach) is a valid alternative to expert evaluation for assessment of surgical skills.40-45 These studies analyzed the ratings of viewers who judged short (2–10 minutes) videos showing dry laboratory, wet laboratory, robotic surgery, and suturing skills (range: 548–2,027 raters per video). The results of these studies demonstrated that crowdsourcing can serve as a low-cost tool for evaluation of psychomotor surgical skills, especially in resource-poor environments. Another important method of judging surgical performance is self-evaluation. Despite its inevitably biased nature, self-evaluation is an indispensable tool for achieving and maintaining expertise. It has been demonstrated that surgical residents’ evaluation of their own skills was more critical than that of their attending surgeons.46 Interestingly, the residents most critical of their own performance were also the highest performing ones,46 suggesting that critical selfevaluation correlates with better surgical performance. An additional evaluative method adopted by musicians to hone and test their performance expertise, but is noticeably absent in the field of surgery, is partaking in competitions. While there is currently no surgical competition designed to identify exceptional surgical skills and talent, it has been shown that a healthy competitive environment enhanced surgical performance and fostered strong interaction among novice surgeons,47,48 even among the participants who declared to not be motivated by competition.49 When not participating in competitions, musicians evaluate their own performance by reviewing and critiquing recordings of their own rehearsal and practice sessions for self-improvement. Similarly, a study of orthopedic surgical residents showed that reviewing intraoperative videos of their own performance improved their orthopedic surgical skills training.50 Finally, the learning method of reviewing prerecorded videos may be especially beneficial when it comes to low-volume procedures, for example, as has been shown for forceps-assisted deliveries.51 Recommendations for surgeons Surgeons can benefit from studying exemplary videos of specific procedures performed or to be performed, and from a supportive but competitive training environment. Low-cost crowdsourcing may be an innovative way of reviewing surgical performance in resourcedeprived environments. Furthermore, novice and experienced

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surgeons alike can benefit from having their skills evaluated and monitored by their peers, and even more importantly, improve surgical performance through continuous, critical self-evaluation. Movement IV: occupational injuries Preserving a healthy body unburdened by pain or injury plays a pivotal role in sustaining the longevity of surgical and musical careers. To meet the high demands of a performance career, professional pianists practice 3 to 5 hours a day,1 comparable with the 21 hours per week median operative time for surgeons.47 Contradicting the common notion that most occupational injuries can be attributed to cumulative “wear and tear” from daily practice, studies have failed to correlate neither higher age or more years of experience with an increased risk of injuries.47 These data suggest that it is how, not how much, one moves that determines his or her risk for performance-related problems. Previous work has shown that professional pianists use their hands in a more ergonomic and efficient manner than amateur pianists do.48 Compared with amateurs, expert pianists perform with lower-energy-cost movements, greater degrees of freedom in their hands and arms, and less muscular force. They use pivoting techniques and flexible movement organization, and cluster disparate gestures to maximize movement efficiency.33 Additionally, they generate rapid motion from more proximal parts by using wrist rotation, which helps alleviate and dissipate tension in the arms.52 Adopting these aforementioned techniques may help surgeons maintain the musculoskeletal health of their hands and extend the longevity of their career.33 However, even the most movement-conscious musician can have performance-related fatigue, pain, and injuries from chronic and exhaustive use of their hands and arms.53-55 Similarly, even the most anatomy-conscious surgeons are prone to operation-related fatigue, pain, and injuries. A study on gynecologic surgeons showed that musculoskeletal fatigue and pain were highly prevalent, with women being affected twice as often as men.56 Another study on orthopedic surgeons found that two-thirds of respondents had a workrelated musculoskeletal disorder.57 Despite the comparably high prevalence of occupational injuries in both professions, our investigation revealed striking differences in responding to them at a personal and institutional level. A comprehensive study of 4,025 professional musicians showed that when confronted with hand, arm, or neck pain associated with playing their instrument, few would hesitate to seek immediate professional help, and most would consider a hiatus from playing.58 To address the prevalence of performance-related injuries among musicians and their coaches, the National Association of Schools of Music mandates that all conservatories include injury prevention and awareness in their curricula.59 In contrast, surgeons are more reluctant to address physical impediments openly and obtain necessary treatment. This disinclination can be partially attributed to innate personality differences between surgeons and the general population.60 A study from the Massachusetts General Hospital demonstrated that surgeons recovering from a hand or wrist fracture chose to return to their operative duties well ahead of the schedule set by their hand surgeons (average elected return to work 25 days after surgery).61 A survey of 260 surgeons found that 40% had sustained injuries at their workplace and 53% of injured surgeons reported that the pain from musculoskeletal injuries had a noticeable effect on their surgical performance. More alarmingly, while 50% of injured surgeons received medical care, only 20% of injured surgeons reported their injuries to the institution.50 Another study of 140 orthopedic surgeons concluded that only 25% of injuries were reported to the institution, while 38% of injured surgeons declared that insufficient institutional resources were available to meet their recovery needs.62

Left untreated, hand injuries can severely impact a surgeon’s job satisfaction,62 curtail his or her surgical career, compromise patient safety, decrease productivity, and increase medical costs to the institution.50 Therefore, it is important to train surgical residents to recognize early symptoms of operation-induced fatigue and pain, properly warm up before and cool down after long operations, and adopt preventative and therapeutic strategies to protect the longterm health of their hands. To help foster open discussions and eradicate the stigma associated with hand tremors and pain among surgeons, wellness and integrative medicine centers should actively engage surgeons to participate in wellness programs that are routinely offered, including yoga, Alexander techniques, meditation, and on-site massage therapy. Recommendations for surgeons Training programs for surgeons should include movementconscious injury prevention in their curricula. Surgeons and trainees should vigilantly monitor their own physical condition and take prompt measures to minimize operation-induced musculoskeletal fatigue and injuries. Moreover, we recommend that institutions allocate sufficient resources to meet the treatment and recovery needs of injured surgeons and trainees; and create workshops that promote the prevention, recognition, and treatment of surgeons and trainees’ workplace injuries and recovery from such injuries. Movement V: performance anxiety and β-blocker usage Both surgery and live musical performances are challenging on physiologic, emotional, and intellectual levels. Given the highpressure, immediate nature of surgery or a live musical performance, surgeons and concert musicians routinely experience acute situational (state) stress and performance anxiety, which manifests through an inflammatory response.63 A biologic correlate has been found among orchestra musicians, in whom key inflammatory markers, including interleukin-6 and C-reactive protein, were found to be significantly elevated during live performance compared with rehearsal.63 Although a small increase in stress hormones can increase alertness and task efficiency, excessive levels of stress hormones can significantly compromise cognitive efficiency, attention, concentration, and motor skills.64 Surgeons and musicians have both resorted to pharmaceutic interventions to combat performance anxiety and/or enhance performance. Two studies found that 19.9% of 1105 German surgeons and 10% of top-ranked German chess players surveyed in 2017 (another cohort that has a high-stress work environment) have reported using cognition-enhancing drugs.65,66 As for the 2,212 musicians surveyed in a national study of orchestral musicians in 1988, 20% of them—similar percentage to the surgeons surveyed— admitted to using β-blockers prior to public performances60 to combat performance anxiety. Musical performance anxiety, also known as stage fright, can cause hyperhidrosis, hyperventilation, and debilitating hand tremor.67 Musical performance anxiety was found to be the leading nonmusculoskeletal medical problem. A 2012 study concluded that 1 in 3 orchestral musicians has severe performance anxiety during live performances.68 A combination of situational factors and circumstantial variables increases the risk of musical performance anxiety, including solo (versus group) performance,69 evaluative (with a jury) versus nonevaluative (without a jury) performance,70,71 and public performance versus private practice.72 An operation is inevitably a solo, evaluative, and public performance. Today, there is limited research on surgeons afflicted with surgical performance anxiety. The most debilitating of the three main physiologic manifestations of musical performance anxiety—hyperhydrosis, hyperventilation,

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and hand tremor—is physiologic hand tremor, which are highfrequency (6–12 Hz), low-amplitude (<1 mm) oscillations caused by a sympathetic, somatic mechanism.73 Because of the high demand for dexterity and complex finger-movement coordination when playing a musical instrument—for example, certain piano works require 11.5 keystrokes per second33—even the minutest tremor can negatively impact performance precision and accuracy. Analogously, hand tremor can have a detrimental impact on surgical precision and patient outcomes, especially in microsurgical procedures,74 during which even the smallest amplitude of tremor can cause significant errors. Notably, a surgeon’s experience has not been shown to play a role in the frequency and magnitude of physiologic hand tremor.75 Studies have shown that physiological tremor can be mitigated by low doses (10–40 mg) of the β-blocker propranolol.76 Unlike other substances consumed for relaxation, including alcohol and benzodiazepine medications, propranolol does not impair higher central nervous system functions.77 A study on musicians showed that the β-blockade mechanism completely eliminates the physical hindrances to performance caused by stage fright, including uncontrollable tremors, sweaty palms, hyperventilation, and dry mouth. Remarkably, the performance quality of musicians who had taken β-blockers was judged to be significantly superior to that of the nonmedicated group by experienced music critics.78 Whereas there is an abundance of data highlighting the performance-enhancing and nontranquilizing effect of propranolol, there are only a few studies of propranolol’s effects on surgeons who are prone to having physiologic symptoms of operational anxiety. However, a double-blind, randomized study found that administering 40 mg of propranolol to surgeons 1 hour before surgery significantly increased surgical performance and decreased anxiety and hand tremor without unintended effects for the surgeon or patient.73 In addition to physiologic stress and anxiety, preventable causes of hand tremors may include fasting, sleep deprivation, fatigue due to physical or mental exertion, dehydration, and excessive ingestion of caffeine.79-82 Preoperative caffeine use has been found to increase change-from-baseline tremor measurements by 31%.81 While some surgeries may be little affected by a tremor, for those that are,

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these studies suggest that in addition to refraining from caffeine use and fasting prior to surgery, the use of β-blocking agents (10–40 mg of propranolol 1 hour prior to surgery) may reduce physiologic hand tremor and improve overall surgical performance and patient outcomes. Recommendations for surgeons The data above suggest that to minimize hand tremor, surgeons may benefit from refraining from fasting, sleep deprivation, fatigue due to physical or mental exertion, dehydration, and excessive ingestion of caffeine prior to surgery. Additionally, surgeons and trainees performing minimally invasive and micro surgeries, and having uncontrollable intrasurgical hand tremors or performance anxiety, may benefit from the use of β-blocking agents. Coda/Conclusion In this review, we have identified 5 key parallels between surgical performance and musical performance (Fig), and provided key recommendations to surgeons that may enhance surgical performance and potentially improve patient outcomes (Table). In summary, our examination of the existing literature on surgical and musical performance has led us to conclude that both professions demand serious commitment to extensive training and deliberate practice and a high level of ambidexterity. Furthermore, surgeons may improve surgical outcomes by adopting expert musicians’ strategies for combating physiologic and psychologic performancerelated issues by using deliberate practice to enhance concentration and error-detection through reflective feedback. Avoiding scheduling complex, high-risk operations the day after returning from a surgical hiatus that lasted for ≥3 days may aid in improving patient outcomes. Taking conscious measures to improve dexterity of the non-dominant hand will improve operative performance. Engaging in continuous peer- and self-evaluation is a low-resource approach that has been shown to help foster a culture of learning and technical perfection. Recording surgeries, especially lowvolume procedures, and reviewing them for self-critique and selfimprovement should be a routine measure for improving surgical

Table Recommendations for improving surgical performance based on strategies adopted by expert musicians. Recommendations for improving surgical performance based on strategies used by expert musicians Performance issue

Musician’s approach

Recommendation for surgeons

Achieving technical virtuosity and consistency

Deliberately practice for 10,000 + hours. and extensive training for 10 + years. Adopt specific exercises to strengthen weak technical areas. Avoid scheduling concerts immediately after being away from consistent and structured practice. Practice special scales, arpeggios, and etudes to improve the independence and strength of the nondominant hand. Receive regular, scheduled coachings and masterclasses with teachers and peers. Record practice sessions and rehearsals for self-critique and self-improvement purposes.

Use deliberate practice to enhance concentration and error-detection through reflective feedback, and partake in virtual-reality training for task-specific training. Avoid scheduling complex, high-risk operations the day after returning from a surgical hiatus lasting ≥3 days. Consider transcranial direction current stimulation to improve the dexterity of the nondominant hand. Have skills regularly evaluated and monitored by peers and engage in continuous self-evaluation. Record surgeries, especially low-volume procedures, and review them for self-critique and self-improvement purposes. Participate in surgical performance competitions for novice surgeons. Practice mindfulness, yoga, Alexander techniques, meditation, and get massage therapy to help prevent, stabilize, and heal injuries. Learn to recognize early signs of surgical occupational injuries, and seek immediate medical help. Avoid fasting, sleep deprivation, strenuous physical or mental exertion, dehydration, and excessive ingestion of caffeine prior to operating. Consider administration of 10 to 40 mg of propranolol 1 hour prior to surgery to reduce hand tremor.

Time-away from practice and performance Unbalanced control of the dominant and nondominant hands Performance plateau and self-complacency Need for private feedback, self-critique and self-improvement Need for out-of-comfort-zone, public and evaluative judgment and recognition Musculoskeletal injury prevention

Musculoskeletal injury treatment Hand tremor not related to performance anxiety Hand tremor related to performance anxiety

Participate in regional and international auditions and multiround competitions. Practice mindfulness, yoga, Alexander techniques, meditation, and get massage therapy to help prevent, stabilize, and heal injuries. Recognize early signs of performance-related injuries, and do not hesitate to seek immediate medical help. Avoid fasting, sleep deprivation, strenuous physical or mental exertion, dehydration, and excessive ingestion of caffeine prior to important performances. Administration of 10 to 40 mg of propranolol 1 hour prior to concert to reduce hand tremor.

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skill. A supportive but competitive training environment that fosters mastery of surgical performance may help trainees to judge their surgical motor skills relative to the skills of their peers and create a desire to improve. Training programs should include in their curricula tips for recognizing early signs of surgical occupational injuries. Hospitals should advise trainees and staff surgeons to seek immediate medical help when repetitive motion injuries occur. Practicing mindfulness, undergoing massage therapy, and engaging in active relaxation with yoga or Alexander techniques can help prevent, stabilize, and heal injuries. Avoiding fasting, sleep deprivation, strenuous physical or mental exertion, dehydration, and excessive ingestion of caffeine prior to a complex surgical procedure can reduce hand tremor. When surgeons or surgical trainees have performance anxiety that results in detectable intra-surgical hand tremors, the administration of β-blocking agents prior to surgery may reduce hand tremor. Further investigation is needed to establish the role of cognitive enhancing pharmacologic agents to combat performance anxiety and improve technical performance. This study has several important limitations: many of the primary data are derived from retrospective and observational studies, which are at risk for selection bias. Another limitation is that the study includes a nonexhaustive limit of the 5 most relevant domains, and that meta-analytical tools could not be applied due to the number and quality of publications on this topic. Nevertheless, as much structure as possible was given to the selection process of relevant domains and included publications using Nominal Group Technique. Furthermore, while this article is focused on operative performance, excellence as a surgeon depends on other factors including interpersonal intelligence, personality, decision-making, and compassion among others, which were not the focus of this study. Nevertheless, as surgeons are ultimately called upon to perform surgery, technical prowess is as essential to the construct of an excellent surgeon as virtuosity is to the makings of a master musician. Because musicians devote a significant portion of their training and professional career to technical refinement and maintenance— even eminent virtuosos like Sergei Rachmaninoff religiously practiced daily technical drills for hours throughout his career—they may be well qualified to share these general concepts with surgeons for whom technical command is an essential contributor, aside from many others, to their professional success. Additionally, while this article focuses on the similarities between surgical and expert musical performance, important differences (e.g., excellence in surgical decision making or patient-surgeon interaction) have not been discussed. Surgery is a performing art. Each surgical procedure is a unique live performance that has immediate and irreversible consequences for both the performer and the audience. Whereas a subpar musical performance may earn the musician an unfavorable review and potentially derail his or her concert career, an unsuccessful performance in the operating room can have life-threatening consequences for the patient. We posit that having surgeons anticipate and address performance issues as comprehensively and as thoroughly as musicians do will improve surgeons’ skill and may improve surgical outcomes and patient safety. Acknowledgment We thank Nicholas Navin, PhD, and Stephanie Deming, B.A. (Bachelor of Arts), for their editorial support. References 1. Krampe RT, Ericsson KA. Maintaining excellence: deliberate practice and elite performance in young and older pianists. J Exp Psychol Gen 1996;125:331-59. 2. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79:S70-81.

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Please cite this article in press as: Mei Rui, Jeffrey E. Lee, Jean-Nicolas Vauthey, and Claudius Conrad, Enhancing surgical performance by adopting expert musicians’ practice and performance strategies, Surgery (2017), doi: 10.1016/j.surg.2017.09.011