Expertise Differences in Fixation, Quiet Eye Duration, and Surgical Performance During Identification and Dissection of

1. Expertise Differences in Fixation, Quiet Eye Duration, and Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve Harvey, A.1 Vickers, JN. 2 Snelgrove, R. 1 Scott, M. 2 & Morrison, S. 2 Department of Surgery 1 Faculty of Kinesiology 2 Association of Surgical Education Orlando, Florida April 24, 2013 1 2

2. Background • Halsted Model • Apprenticeship Based • Graded Responsibility 2

4. Background • High level athlete gaze, focus of attention, and relation to motor skill has been studied for years • Extensive research in sport on the Quiet Eye (QE) • Over 70 refereed studies to date in over 15 sports Quiet eye location 4

5. Background • Quiet eye fixation = fixation on a specific location within 1 degree of visual angle (foveal vision) for more than 100 ms prior to successful completion of a critical movement • Elite performers have longer duration quiet eye characteristic • Quiet eye is also longer during high levels of performance • QE training has proven successful in a wide range of sports

6. Background • Limited literature focus of attention in surgical skills acquirement or training • Moulton et al – “Slowing Down” at critical moments

7. Purpose • To examine the surgical movements, fixation durations, and Quiet Eye durations of highly experienced (HE) & less experienced (LE) surgeons/residents 7

8. Hypotheses • HE surgeons will be ranked higher than LE surgeons (blinded external review) • HE surgeons will ‘slow down’ using longer Quiet Eye durations on the Recurrent Laryngeal Nerve 8

9. Methods • Ten Volunteers • 3 HE surgeons (M = 2391 operations) • 7 LE surgeons (M = 37 operations) • Equipment • ASL mobile eye tracker • Synchronized external video of surgical movements 9

10. Surgical Movements and Gaze Data Surgical Movements Gaze Data

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12. Results – Global Rating Scores 12

13. Results – Global Rating ScoreRespect for Tissue x Phase Phase 1: Identify Inferior Thyroid Artery Phase 2: Identify Recurrent Laryngeal Nerve Phase 3: Divide Ligament of Berry p < .04 13 13

14. Results – Movement Time (MT%) p < .98 14

15. Total Fixation Duration by Phase

16. Quiet Eye (QE) Duration on Recurrent Laryngeal Nerve p < .008 16 15

17. Summary • Relative to LE, HE surgeons had: • Higher global rating scores • No significant differences in operating time, or hand movement times (MT%) • Longer fixation durations on the Ligament of Berry • Higher QE duration on the RLN prior to blunt and sharp dissections 17

18. Conclusions • HE surgeon’s longer QE duration reveals greater focus of attention on critical structures prior to and during surgical movements • HE surgeon’s longer fixations on the LofB suggest the use of a perceptual anchor that is used to define the underlying structures • HE surgeonscognitivelyslow down during critical phases of the operation • Moulton & Epstein are correct, “slowing down” is a critical cognitive skill of expert surgeons

19. Future Directions • Quiet Eye Training • Durable • Robust under conditions of stress/anxiety • Increases success under conditions of exhaustion • July 2013 – knot tying for R1 surgical residents