Surgeon Heidi Nelson, M.D. wanted advice on making surgery safer. Not for patients this time, but for surgeons and their teams.

"We can't manage what we cannot measure. The surgical world is changing at a fast pace and we want to make sure the environment is fully supportive of the increasing complexity of the jobs to be done," says Dr. Nelson.

While she says that surgeons will do what needs to be done to get good patient outcomes, unusual physical and mental strains come with a cost.

"For rare cases or the short term that is fine but it is not sustainable."

As chair of the Department of Surgery at Mayo Clinic in Rochester, Minn., she didn't have to go far: At Mayo Clinic, there are engineers just down the hall. In the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, a team of health systems engineering experts was ready to answer her questions.

Dr. Nelson sat down with Katherine Law, Ph.D., and Susan Hallbeck, Ph.D., Robert D. and Patricia E. Kern Scientific Director for Health Care Systems Engineering. Together they began a collaboration to investigate and improve safety in the operating room and surgical team wellness, starting with surgeon workload. The team's results, published in the Annals of Surgery, examined workload across all specialties within of the Department of Surgery.

Using surveys, the team identified potential predictors of high workload for future performance improvement. The researchers received surveys from 34 surgeons, following a total of 662 surgeries. The survey used a customized version of the NASA Task Load Index (a validated instrument that enables subjective measurement of mental and physical workload). They connected this to 506 sets of associated patient characteristics (those who consented for their data to be used) and procedural data from across 10 different surgical specialties.

Surgeons reported difficulty levels higher than expected for 22 percent of procedures, meaning that workload was significantly higher and durations significantly longer. Moreover, surgeons reported poorer perceived performance during cases with unexpectedly high difficulty.

In general, the researchers told Dr. Nelson, when a surgeon found a procedure more difficult than expected, it required significantly higher mental and physical demands. Further, this led to self-perceptions of poorer performance, independent of patient outcomes. To Dr. Nelson and the health care systems engineering team, these are warning signs of physical and cognitive burden, which can lead to injury and burnout, the very things they hope to prevent. She says that, then the question became "what could be different in our 'OR [operating room] of the future'?"

The team has multiple investigations underway as a result. Their second paper, also published in the Annals of Surgery, describes further analysis into a single surgical specialty—colon and rectal surgery—and quantifying the human 'cost' of performing a particular procedure.

"We believe this to be the only program of its type in the world, where human factors and ergonomics research is embedded into surgical practice," says Dr. Hallbeck. "Together we are collaborating to develop the OR of the future."

- Elizabeth Zimmermann

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