Mental practice: effective stress management training for novice surgeons

J Am Coll Surg. 2011 Feb;212(2):225-33. doi: 10.1016/j.jamcollsurg.2010.09.025.


Background: Surgeons are often subject to excessive levels of acute stress that can impair their performance. Mental practice (MP) is a strategy used in other high-performance industries to alleviate anxiety. This study investigated if MP reduces stress in novice surgeons.

Study design: A prospective, randomized controlled design was used with 20 novice surgeons recruited by random sampling. After baseline testing, participants underwent training on an evidence-based virtual reality (VR) curriculum. They then performed 5 VR laparoscopic cholecystectomies (LC) after being randomized to MP or control groups. The MP group performed 30 minutes of MP using a validated MP training protocol before each LC; control participants conducted an unrelated activity. Stress was assessed subjectively using the validated State-Trait Anxiety-Inventory (STAI) questionnaire and objectively with a continuous heart rate (HR) monitor and salivary cortisol. Mental imagery was assessed using the validated mental imagery questionnaire.

Results: Eighteen participants completed the study. There were no intergroup differences in baseline stress, imagery, or technical ability. Comparing the MP group with controls, subjective stress (STAI) was lower for the MP group (median 8.40 vs 11.31, p < 0.01). Objective stress was also significantly reduced for the MP group in terms of the average HR (median 72 vs 88 beats/minute, p < 0.0001), maximum HR (median 102 vs 119 beats/minute, p < 0.01), and cortisol (median 2.26 vs 3.85 nmol/L, p < 0.05). Significant negative correlations were obtained between stress and imagery, indicating that improved imagery was associated with lower stress (p < 0.05).

Conclusions: A short period of MP reduces the subjective, cardiovascular, and neuroendocrine response to stress on a VR simulator. Additional research should determine whether this effect extends beyond novice surgeons and transfers to the operating room.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Anxiety / etiology
  • Anxiety / prevention & control
  • Biomarkers / metabolism
  • Computer Simulation
  • Female
  • General Surgery*
  • Heart Rate
  • Humans
  • Hydrocortisone / metabolism
  • Imagery, Psychotherapy*
  • Male
  • Operating Rooms
  • Physicians / psychology*
  • Prospective Studies
  • Saliva / metabolism
  • Stress, Psychological / complications
  • Stress, Psychological / diagnosis*
  • Stress, Psychological / etiology
  • Stress, Psychological / therapy*
  • Surveys and Questionnaires
  • Task Performance and Analysis
  • Treatment Outcome
  • Workforce


  • Biomarkers
  • Hydrocortisone