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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 current...

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Autores principales: Hannah, Theodore C., Turner, Daniel, Kellner, Rebecca, Bederson, Joshua, Putrino, David, Kellner, Christopher P.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Frontiers Media S.A. 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8888846/
https://www.ncbi.nlm.nih.gov/pubmed/35250509
http://dx.doi.org/10.3389/fnhum.2022.705238
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author Hannah, Theodore C.
Turner, Daniel
Kellner, Rebecca
Bederson, Joshua
Putrino, David
Kellner, Christopher P.
author_facet Hannah, Theodore C.
Turner, Daniel
Kellner, Rebecca
Bederson, Joshua
Putrino, David
Kellner, Christopher P.
author_sort Hannah, Theodore C.
collection PubMed
description 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.
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spelling pubmed-88888462022-03-03 Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review Hannah, Theodore C. Turner, Daniel Kellner, Rebecca Bederson, Joshua Putrino, David Kellner, Christopher P. Front Hum Neurosci Neuroscience 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. Frontiers Media S.A. 2022-02-16 /pmc/articles/PMC8888846/ /pubmed/35250509 http://dx.doi.org/10.3389/fnhum.2022.705238 Text en Copyright © 2022 Hannah, Turner, Kellner, Bederson, Putrino and Kellner. https://creativecommons.org/licenses/by/4.0/This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
spellingShingle Neuroscience
Hannah, Theodore C.
Turner, Daniel
Kellner, Rebecca
Bederson, Joshua
Putrino, David
Kellner, Christopher P.
Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review
title Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review
title_full Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review
title_fullStr Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review
title_full_unstemmed Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review
title_short Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review
title_sort neuromonitoring correlates of expertise level in surgical performers: a systematic review
topic Neuroscience
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8888846/
https://www.ncbi.nlm.nih.gov/pubmed/35250509
http://dx.doi.org/10.3389/fnhum.2022.705238
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