Performing under pressure: quiet eye training improves surgical knot-tying performance

Surgery. 2014 Nov;156(5):1089-96. doi: 10.1016/j.surg.2014.05.004. Epub 2014 Aug 21.


Background: We examined the effectiveness of traditional technical training (TT) and quiet eye training (QET) on the performance of 1-handed square knot tying among first-year surgery residents under normal and high-anxiety conditions.

Methods: Twenty surgery residents were assigned randomly to 1 of 2 groups and completed pretest, training, and simple and complex retention tests under conditions of high and low anxiety. The TT group received traditional instruction on improving hand movements; the QET group received feedback on their gaze behaviors. Participants wore an eye tracker that recorded simultaneously their gaze and hand movements. Dependent variables were knot tying performance (%), quiet eye duration (%), number of fixations, and total movement time (s).

Results: Both groups improved their knot tying performance (P < .05) from pretest to the low anxiety conditions (mean difference: QET, 28%; TT, 17%); however, only the QET group maintained their knot tying performance under the high-anxiety conditions (mean difference: QET, 18%; P < .05), with the TT group decreasing their performance close to pretest levels (P > .05). The QET group also demonstrated more efficient gaze and hand movements post training.

Conclusion: These data demonstrate the effectiveness of training gaze behaviors, not only to improve the effectiveness and efficiency of performance, but also to mediate negative effects of anxiety on performance. These findings may have important implications for medical educators and practitioners, as well as surgeons who may be (re)training or learning new procedures.

Publication types

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

MeSH terms

  • Adult
  • Eye Movements*
  • Heart Rate
  • Humans
  • Stress, Psychological
  • Suture Techniques / education*