Association of Residents' Neural Signatures With Stress Resilience During Surgery

The application of fNIRS in studies on occupational workload: a systematic review

Background

Occupational workload can contribute to significant health problems such as chronic stress, fatigue and burnout. To investigate the underlying mechanisms, it is necessary to monitor brain activity in real work environments. Functional near-infrared spectroscopy (fNIRS) is a portable, non-invasive neuroimaging method that captures neural correlates of occupational workload under natural conditions. However, despite its increasing application, a comprehensive overview of fNIRS-based research in this field is lacking. Therefore, this systematic review examines how fNIRS can be utilized to investigate occupational workload.

Methods

Following PRISMA 2020 guidelines, we conducted our systematic review by searching Web of Science, PubMed, and Scopus between November 15, 2023 and March 20, 2025. We included all studies published in English or German at any date, as long as they examined healthy adult professionals performing occupational tasks with functional near-infrared spectroscopy (fNIRS). Extracted data included study characteristics, workload details, signal processing methods, main fNIRS findings, and study quality, assessed using the JBI Critical Appraisal Tool.

Results

We included 41 studies. Of these, 23 reported a significant increase in oxygenated hemoglobin (HbO) concentration and functional connectivity in the prefrontal cortex (PFC) under higher occupational workload conditions. Only five studies examined typical office tasks. Nine studies analyzed differences in cortical activation between experts and novices, with experts showing increased HbO concentration in the PFC than novices. Regarding methodology, 26 studies used standardized optode placements, while only 17 applied systemic and extracerebral artifact correction. Small sample sizes and the absence of randomized controlled trials limited the reliability and reproducibility of the findings.

Conclusion

Functional near-infrared spectroscopy effectively detects neural correlates of occupational workload and provides objective insights into cognitive demands in real-world work settings. Standardizing optode placement, harmonizing signal-processing methods, and increasing sample sizes would enhance the validity and comparability of future research. Expanding investigations to typical office environments is also crucial for understanding daily workload and for developing interventions that promote employee well-being and productivity. Overall, fNIRS represents a promising tool for establishing evidence-based workplace health promotion strategies across diverse occupational settings.

Enhancing Surgical Robotic Skills Through Performance-Guided Training: A Swimmer's Approach for Defining Key Metrics

Background

In swimming, a combination of strength, endurance, and targeted skill training significantly enhances performance, particularly by balancing aerobic and anaerobic conditioning. Similarly, in surgery, improving motor control and stamina during lengthy operations, particularly for precise movements like suturing or tissue manipulation, is essential. This literature review aims to explore the parallels between the training paradigms of elite swimming and robotic-assisted surgical practice, focusing on skill acquisition, training methodologies, and performance-guided feedback systems. The hypothesis suggests a significant link between these training principles, offering opportunities to optimize surgeon training, particularly in robotic-assisted surgery.

Database

A systematic review was conducted following PRISMA guidelines. A thorough examination of existing literature in both elite swimming and robotic-assisted surgery training identified key elements of skill development, feedback mechanisms, and structured progression. Sources included peer-reviewed studies on swimming techniques, cognitive training in surgery, and simulation-based training programs that emphasize performance-driven improvements.

Conclusion

The review identified significant parallels between swimming and robotic-assisted surgery training, with both fields emphasizing structured, feedback-driven approaches to enhance precision and skill. Techniques such as video analysis in swimming and real-time digital feedback in surgery were found to be effective in improving outcomes. Simulation-based training also plays a crucial role in refining skills and promoting adaptability in both disciplines. Applying elite swimming methodologies, particularly those centered on feedback, precision, and structured progression, could help develop key metrics to enhance surgical training programs, in robotic-assisted surgery. Future research could further optimize surgeon training, potentially leading to improved performance and better patient outcomes in robotic procedures.

The role of anesthesia in peri‑operative neurocognitive disorders: Molecular mechanisms and preventive strategies

Peri-operative neurocognitive disorders (PNDs) include postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). Children and the elderly are the two populations most vulnerable to the development of POD and POCD, which results in both high morbidity and mortality. There are many factors, including neuroinflammation and oxidative stress, that are associated with POD and POCD. General anesthesia is a major risk factor of PNDs. However, the molecular mechanisms of PNDs are poorly understood. Dexmedetomidine (DEX) is a useful sedative agent with analgesic properties, which significantly improves POCD in elderly patients. In this review, the current understanding of anesthesia in PNDs and the protective effects of DEX are summarized, and the underlying mechanisms are further discussed.

Objective Assessment of Cognitive Workload in Surgery: A Systematic Review

OBJECTIVE

To systematically review technologies that objectively measure CWL in surgery, assessing their psychometric and methodological characteristics.

SUMMARY BACKGROUND DATA

Surgical tasks involving concurrent clinical decision-making and the safe application of technical and non-technical skills require a substantial cognitive demand and resource utilization. Cognitive overload leads to impaired clinical decision-making and performance decline. Assessing cognitive workload (CWL) could enable interventions to alleviate burden and improve patient safety.

METHODS

Ovid MEDLINE, OVID Embase, the Cochrane Library and IEEE Xplore databases were searched from inception to August 2023. Full-text, peer-reviewed original studies in a population of surgeons, anesthesiologists or interventional radiologists were considered, with no publication date constraints. Study population, task paradigm, stressor, Cognitive Load Theory (CLT) domain, objective and subjective parameters, statistical analysis and results were extracted. Studies were assessed for a) definition of CWL, b) details of the clinical task paradigm, and c) objective CWL assessment tool. Assessment tools were evaluated using psychometric and methodological characteristics.

RESULTS

10790 studies were identified; 9004 were screened; 269 full studies were assessed for eligibility, of which 67 met inclusion criteria. The most widely used assessment modalities were autonomic (32 eye studies and 24 cardiac). Intrinsic workload (e.g. task complexity) and germane workload (effect of training or expertize) were the most prevalent designs investigated. CWL was not defined in 30 of 67 studies (44.8%). Sensitivity was greatest for neurophysiological instruments (100% EEG, 80% fNIRS); and across modalities accuracy increased with multi-sensor recordings. Specificity was limited to cardiac and ocular metrics, and was found to be sub-optimal (50% and 66.67%). Cardiac sensors were the least intrusive, with 54.2% of studies conducted in naturalistic clinical environments (higher ecological validity).

CONCLUSION

Physiological metrics provide an accessible, objective assessment of CWL, but dependence on autonomic function negates selectivity and diagnosticity. Neurophysiological measures demonstrate favorable sensitivity, directly measuring brain activation as a correlate of cognitive state. Lacking an objective gold standard at present, we recommend the concurrent use of multimodal objective sensors and subjective tools for cross-validation. A theoretical and technical framework for objective assessment of CWL is required to overcome the heterogeneity of methodological reporting, data processing, and analysis.

Surgical Sabermetrics: A Scoping Review of Technology-enhanced Assessment of Nontechnical Skills in the Operating Room

OBJECTIVE

To evaluate the current evidence for surgical sabermetrics: digital methods of assessing surgical nontechnical skills and investigate the implications for enhancing surgical performance.

BACKGROUND

Surgeons need high-quality, objective, and timely feedback to optimize performance and patient safety. Digital tools to assess nontechnical skills have the potential to reduce human bias and aid scalability. However, we do not fully understand which of the myriad of digital metrics of performance assessment have efficacy for surgeons.

METHODS

A systematic review was conducted by searching PubMed, EMBASE, CINAHL, and PSYCINFO databases following PRISMA-ScR guidelines. MeSH terms and keywords included "Assessment," "Surgeons," and "Technology". Eligible studies included a digital assessment of nontechnical skills for surgeons, residents, and/or medical students within an operative context.

RESULTS

From 19,229 articles screened, 81 articles met the inclusion criteria. The studies varied in surgical specialties, settings, and outcome measurements. A total of 122 distinct objective, digital metrics were utilized. Studies digitally measured at least 1 category of surgical nontechnical skill using a single (n=54) or multiple objective measures (n=27). The majority of studies utilized simulation (n=48) over live operative settings (n=32). Surgical Sabermetrics has been demonstrated to be beneficial in measuring cognitive load (n=57), situation awareness (n=24), communication (n=3), teamwork (n=13), and leadership (n=2). No studies measured intraoperative decision-making.

CONCLUSIONS

The literature detailing the intersection between surgical data science and operative nontechnical skills is diverse and growing rapidly. Surgical Sabermetrics may provide a promising modifiable technique to achieve desirable outcomes for both the surgeon and the patient. This study identifies a diverse array of measurements possible with sensor devices and highlights research gaps, including the need for objective assessment of decision-making. Future studies may advance the integration of physiological sensors to provide a holistic assessment of surgical performance.

Assessment of Surgical Tasks Using Neuroimaging Dataset (ASTaUND)

Functional near-infrared spectroscopy (fNIRS) is a neuroimaging tool for studying brain activity in mobile subjects. Open-access fNIRS datasets are limited to simple and/or motion-restricted tasks. Here, we report a fNIRS dataset acquired on mobile subjects performing Fundamentals of Laparoscopic Surgery (FLS) tasks in a laboratory environment. Demonstrating competency in the FLS tasks is a prerequisite for board certification in general surgery in the United States. The ASTaUND data set was acquired over four different studies. We provide the relevant information about the hardware, FLS task execution protocols, and subject demographics to facilitate the use of this open-access data set. We also provide the concurrent FLS scores, a quantitative metric for surgical skill assessment developed by the FLS committee. This data set is expected to support the growing field of assessing surgical skills via neuroimaging data and provide an example of data processing pipeline for use in realistic, non-restrictive environments.

A scoping review of emotions and related constructs in simulation-based education research articles

BACKGROUND

While acknowledgement of emotions' importance in simulation-based education is emerging, there are concerns regarding how education researchers understand the concept of emotions for them to deliberately incorporate emotionally charged scenarios into simulation-based education. This concern is highlighted especially in the context of medical education often lacking strong theoretical integration. To map out how current simulation-based education literature conceptualises emotion, we conducted a scoping review on how emotions and closely related constructs (e.g. stress, and emotional intelligence) are conceptualised in simulation-based education articles that feature medical students, residents, and fellows.

METHODS

The scoping review was based on articles published in the last decade identified through database searches (EMBASE and Medline) and hand-searched articles. Data extraction included the constructs featured in the articles, their definitions, instruments used, and the types of emotions captured. Only empirical articles were included (e.g. no review or opinion articles). Data were charted via descriptive analyses.

RESULTS

A total of 141 articles were reviewed. Stress was featured in 88 of the articles, while emotions and emotional intelligence were highlighted in 45 and 34 articles respectively. Conceptualisations of emotions lacked integration of theory. Measurements of emotions mostly relied on self-reports while stress was often measured via physiological and self-report measurements. Negative emotions such as anxiety were sometimes seen as interchangeable with the term stress. No inferences were made about specific emotions of participants from their emotional intelligence.

CONCLUSIONS

Our scoping review illustrates that learners in simulation-based education are most often anxious and fearful. However, this is partially due to medical education prioritising measuring negative emotions. Further theoretical integration when examining emotions and stress may help broaden the scope towards other kinds of emotions and better conceptualisations of their impact. We call for simulation education researchers to reflect on how they understand emotions, and whether their understanding may neglect any specific aspect of affective experiences their simulation participants may have.

Optical neuroimaging and neurostimulation in surgical training and assessment: A state-of-the-art review

Introduction

Functional near-infrared spectroscopy (fNIRS) is a non-invasive optical neuroimaging technique used to assess surgeons' brain function. The aim of this narrative review is to outline the effect of expertise, stress, surgical technology, and neurostimulation on surgeons' neural activation patterns, and highlight key progress areas required in surgical neuroergonomics to modulate training and performance.

Methods

A literature search of PubMed and Embase was conducted to identify neuroimaging studies using fNIRS and neurostimulation in surgeons performing simulated tasks.

Results

Novice surgeons exhibit greater haemodynamic responses across the pre-frontal cortex than experts during simple surgical tasks, whilst expert surgical performance is characterized by relative prefrontal attenuation and upregulation of activation foci across other regions such as the supplementary motor area. The association between PFC activation and mental workload follows an inverted-U shaped curve, activation increasing then attenuating past a critical inflection point at which demands outstrip cognitive capacity Neuroimages are sensitive to the impact of laparoscopic and robotic tools on cognitive workload, helping inform the development of training programs which target neural learning curves. FNIRS differs in comparison to current tools to assess proficiency by depicting a cognitive state during surgery, enabling the development of cognitive benchmarks of expertise. Finally, neurostimulation using transcranial direct-current-stimulation may accelerate skill acquisition and enhance technical performance.

Conclusion

FNIRS can inform the development of surgical training programs which modulate stress responses, cognitive learning curves, and motor skill performance. Improved data processing with machine learning offers the possibility of live feedback regarding surgeons' cognitive states during operative procedures.

Using electroencephalography to explore neurocognitive correlates of procedural proficiency: A pilot study to compare experts and novices during simulated endotracheal intubation

The objective of this study was to explore the use of EEG as a measure of neurocognitive engagement during a procedural task. In this observational study, self-reported cognitive load, observed performance, and EEG signatures in experts and novices were compared during simulated endotracheal intubation. Twelve medical students (novices) and eight senior anesthesiology trainees (experts) were included in the study. Experts reported significantly lower cognitive load (P < 0.001) and outperformed novices based on the observational checklist (P < 0.001). EEG signatures differed significantly between the experts and novices. Experts showed a greater increase in delta and theta band amplitudes, especially in temporal and frontal locations and in right occipital areas for delta. A machine learning algorithm showed 83.3 % accuracy for expert-novice skill classification using the selected EEG features. Performance scores were positively correlated (P < 0.05) with event-related amplitudes for delta and theta bands at locations where experts and novices showed significant differences. Increased delta and frontal/midline theta oscillations on EEG suggested that experts had better attentional control than novices. This pilot study provides initial evidence that EEG may be a useful, noninvasive measure of neurocognitive engagement in operational settings and that it has the potential to complement traditional clinical skills assessment.

The neurophysiology of intraoperative error: An EEG study of trainee surgeons during robotic-assisted surgery simulations

Surgeons operate in mentally and physically demanding workspaces where the impact of error is highly consequential. Accurately characterizing the neurophysiology of surgeons during intraoperative error will help guide more accurate performance assessment and precision training for surgeons and other teleoperators. To better understand the neurophysiology of intraoperative error, we build and deploy a system for intraoperative error detection and electroencephalography (EEG) signal synchronization during robot-assisted surgery (RAS). We then examine the association between EEG data and detected errors. Our results suggest that there are significant EEG changes during intraoperative error that are detectable irrespective of surgical experience level.

Electroencephalography can provide advance warning of technical errors during laparoscopic surgery

BACKGROUND

Intraoperative adverse events lead to patient injury and death, and are increasing. Early warning systems (EWSs) have been used to detect patient deterioration and save lives. However, few studies have used EWSs to monitor surgical performance and caution about imminent technical errors. Previous (non-surgical) research has investigated neural activity to predict future motor errors using electroencephalography (EEG). The present proof-of-concept cohort study investigates whether EEG could predict technical errors in surgery.

METHODS

In a large academic hospital, three surgical fellows performed 12 elective laparoscopic general surgeries. Audiovisual data of the operating room and the surgeon's neural activity were recorded. Technical errors and epochs of good surgical performance were coded into events. Neural activity was observed 40 s prior and 10 s after errors and good events to determine how far in advance errors were detected. A hierarchical regression model was used to account for possible clustering within surgeons. This prospective, proof-of-concept, cohort study was conducted from July to November 2021, with a pilot period from February to March 2020 used to optimize the technique of data capture and included participants who were blinded from study hypotheses.

RESULTS

Forty-five technical errors, mainly due to too little force or distance (n = 39), and 27 good surgical events were coded during grasping and dissection. Neural activity representing error monitoring (p = .008) and motor uncertainty (p = .034) was detected 17 s prior to errors, but not prior to good surgical performance.

CONCLUSIONS

These results show that distinct neural signatures are predictive of technical error in laparoscopic surgery. If replicated with low false-alarm rates, an EEG-based EWS of technical errors could be used to improve individualized surgical training by flagging imminent unsafe actions-before errors occur and cause patient harm.

Use of neuroimaging to measure neurocognitive engagement in health professions education: a scoping review

PURPOSE

To map the current literature on functional neuroimaging use in medical education research as a novel measurement modality for neurocognitive engagement, learning, and expertise development.

METHOD

We searched PubMed, Embase, Cochrane, ERIC, and Web of Science, and hand-searched reference lists of relevant articles on April 4, 2019, and updated the search on July 7, 2020. Two authors screened the abstracts and then full-text articles for eligibility based on inclusion criteria. The data were then charted, synthesized, and analyzed descriptively.

RESULTS

Sixty-seven articles published between 2007 and 2020 were included in this scoping review. These studies used three main neuroimaging modalities: functional magnetic resonance imaging, functional near-infrared spectroscopy, and electroencephalography. Most of the publications (90%, n = 60) were from the last 10 years (2011-2020). Although these studies were conducted in 16 countries, 68.7% (n = 46) were from three countries: the USA (n = 21), UK (n = 15), and Canada (n = 10). These studies were mainly non-experimental (74.6%, n = 50). Most used neuroimaging techniques to examine psychomotor skill development (57%, n = 38), but several investigated neurocognitive correlates of clinical reasoning skills (22%, n = 15).

CONCLUSION

This scoping review maps the available literature on functional neuroimaging use in medical education. Despite the heterogeneity in research questions, study designs, and outcome measures, we identified a few common themes. Included studies are encouraging of the potential for neuroimaging to complement commonly used measures in education research and may help validate/challenge established theoretical assumptions and provide insight into training methods. This review highlighted several areas for further research. The use of these emerging technologies appears ripe for developing precision education, establishing viable study protocols for realistic operational settings, examining team dynamics, and exploring applications for real-time monitoring/intervention during critical clinical tasks.

STOPS: A Coping Framework for Surgeons Who Experience Intraoperative Error

OBJECTIVE

To investigate the steps faculty surgeons take upon experiencing intraoperative error and synthesize these actions to offer a framework for coping with errors.

BACKGROUND

While intraoperative errors are inevitable, formal training in error recovery is insufficient and there are no established curricula that teach surgeons how to deal with the intraoperative error. This is problematic because insufficient error recovery is detrimental to both patient outcomes and surgeon psychological well-being.

METHODS

We conducted a thematic analysis. One-hour in-depth semistructured interviews were conducted with faculty surgeons from 3 hospitals. Surgeons described recent experiences with intraoperative error. Interviews were transcribed and coded. Analysis allowed for development of themes regarding responses to errors and coping strategies.

RESULTS

Twenty-seven surgeons (30% female) participated. Upon completion of the analysis, themes emerged in 3 distinct areas: (1) Exigency, or a need for training surgical learners how to cope with intraoperative errors, (2) Learning, or how faculty surgeons themselves learned to cope with intraoperative errors, and (3) Responses, or how surgeons now handle intraoperative errors. The latter category was organized into the STOPS framework: Intraoperative errors could produce STOPS: Stop, Talk to your Team, Obtain Help, Plan, Succeed.

CONCLUSIONS AND RELEVANCE

This study provides both novel insight into how surgeons cope with intraoperative errors and a framework that may be of great use to trainees and faculty alike.

Methods and Measures for Mental Stress Assessment in Surgery: A Systematic Review of 20 Years of Literature

Real-time mental stress monitoring from surgeons and surgical staff in operating rooms may reduce surgical injuries, improve performance and quality of medical care, and accelerate implementation of stress-management strategies. Motivated by the increase in usage of objective and subjective metrics for cognitive monitoring and by the gap in reviews of experimental design setups and data analytics, a systematic review of 71 studies on mental stress and workload measurement in surgical settings, published in 2001-2020, is presented. Almost 61% of selected papers used both objective and subjective measures, followed by 25% that only administered subjective tools - mostly consisting of validated instruments and customized surveys. An overall increase in the total number of publications on intraoperative stress assessment was observed from mid-2010 s along with a momentum in the use of both subjective and real-time objective measures. Cardiac activity, including heart-rate variability metrics, stress hormones, and eye-tracking metrics were the most frequently and electroencephalography (EEG) was the least frequently used objective measures. Around 40% of selected papers collected at least two objective measures, 41% used wearable devices, 23% performed synchronization and annotation, and 76% conducted baseline or multi-point data acquisition. Furthermore, 93% used a variety of statistical techniques, 14% applied regression models, and only one study released a public, anonymized dataset. This review of data modalities, experimental setups, and analysis techniques for intraoperative stress monitoring highlights the initiatives of surgical data science and motivates research on computational techniques for mental and surgical skills assessment and cognition-guided surgery.

Implementing mindfulness meditation in hand surgery training: a feasibility study

Background

Surgery can be stressful, requiring decision-making and performance under pressure. The COVID-19 pandemic has further challenged surgeons’ well-being and training. Excess stress adversely affects well-being, technical and non-technical performance, and, by extension, patient care. Little emphasis has been placed on interventions to improve individual surgeons’ stress resilience despite mindfulness training being robustly linked to resilience, well-being, and improved executive function and performance. This feasibility study aimed to evaluate the effect and acceptability of a mindfulness meditation session on a group of surgical trainees during a hand fracture fixation course.

Methods

All participants of a single-day hand fracture fixation course were invited to take part in the study, and randomised into two groups. The intervention group experienced a 10-min guided meditation session before their assessment, while the control group did not. Basic demographics, inherent ‘trait’ mindfulness, change in mood, and perceived acceptability were compared between the two groups.

Results

The 17 participants were demographically similar, as were their self-reported mood scores until after the meditation, where they diverged significantly (p < .01, t-test), with the meditation group feeling more relaxed and calm. Meditation as an intervention was considered largely acceptable.

Conclusions

Mindfulness meditation is established in improving stress resilience, relevant to surgeon well-being, performance, and patient care. This feasibility study suggests benefit and acceptability, and potential for further research in designing a targeted programme for surgeons, to reduce stress sensitivity, and improve performance, joy, and well-being within surgical training.

Level of evidence: Level III, Therapeutic study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00238-022-01962-1.

Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review

Surgical expertise does not have a clear definition and is often culturally associated with power, authority, prestige, and case number rather than more objective proxies of excellence. Multiple models of expertise progression have been proposed including the Dreyfus model, however, they all currently require subjective evaluation of skill. Recently, efforts have been made to improve the ways in which surgical excellence is measured and expertise is defined using artificial intelligence, video recordings, and accelerometers. However, these aforementioned methods of assessment are still subjective or indirect proxies of expertise, thus uncovering the neural mechanisms that differentiate expert surgeons from trainees may enhance the objectivity of surgical expertise validation. In fact, some researchers have already suggested that their neural imaging-based expertise classification methods outperform currently used methods of surgical skill certification such as the Fundamentals of Laparoscopic Surgery (FLS) scores. Such imaging biomarkers would not only help better identify the highest performing surgeons, but could also improve residency programs by providing more objective, evidence-based feedback and developmental milestones for those in training and perhaps act as a marker of surgical potential in medical students. Despite the potential advantages of using neural imaging in the assessment of surgical expertise, this field of research remains in its infancy. This systematic review identifies studies that have applied neuromonitoring in assessing surgical skill across levels of expertise. The goals of this review are to identify (1) the strongest neural indicators of surgical expertise, (2) the limitations of the current literature on this subject, (3) the most sensible future directions for further study. We found substantial evidence that surgical expertise can be delineated by differential activation and connectivity in the prefrontal cortex (PFC) across multiple task and neuroimaging modalities. Specifically, novices tend to have greater PFC activation than experts under standard conditions in bimanual and decision-making tasks. However, under high temporal demand tasks, experts had increased PFC activation whereas novices had decreased PFC activation. Common limitations uncovered in this review were that task difficulty was often insufficient to delineate between residents and attending. Moreover, attending level involvement was also low in multiple studies which may also have contributed to this issue. Most studies did not analyze the ability of their neuromonitoring findings to accurately classify subjects by level of expertise. Finally, the predominance of fNIRS as the neuromonitoring modality limits our ability to uncover the neural correlates of surgical expertise in non-cortical brain regions. Future studies should first strive to address these limitations. In the longer term, longitudinal within-subjects design over the course of a residency or even a career will also advance the field. Although logistically arduous, such studies would likely be most beneficial in demonstrating effects of increasing surgical expertise on regional brain activation and inter-region connectivity.

Neuroenhancement in surgeons: benefits, risks and ethical dilemmas

Background

Surgeons traditionally aim to reduce mistakes in healthcare through repeated training and advancement of surgical technology. Recently, performance-enhancing interventions such as neurostimulation are emerging which may offset errors in surgical practice.

Methods

Use of transcranial direct-current stimulation (tDCS), a novel neuroenhancement technique that has been applied to surgeons to improve surgical technical performance, was reviewed. Evidence supporting tDCS improvements in motor and cognitive performance outside of the field of surgery was assessed and correlated with emerging research investigating tDCS in the surgical setting and potential applications to wider aspects of healthcare. Ethical considerations and future implications of using tDCS in surgical training and perioperatively are also discussed.

Results

Outside of surgery, tDCS studies demonstrate improved motor performance with regards to reaction time, task completion, strength and fatigue, while also suggesting enhanced cognitive function through multitasking, vigilance and attention assessments. In surgery, current research has demonstrated improved performance in open knot-tying, laparoscopic and robotic skills while also offsetting subjective temporal demands. However, a number of ethical issues arise from the potential application of tDCS in surgery in the form of safety, coercion, distributive justice and fairness, all of which must be considered prior to implementation.

Conclusion

Neuroenhancement may improve motor and cognitive skills in healthcare professions with impact on patient safety. Implementation will require accurate protocols and regulations to balance benefits with the associated ethical dilemmas, and to direct safe use for clinicians and patients.