Content: We are grateful for Mithra's presentation this week. As before, I will return to the past. When men were men and women were women, we would be on call often for 24 days/24 hours over a 30 day period. It was a badge of courage to be able to take good care of patients and sleep minimally. Then the pendulum swung in the other direction, resident physicians were limited to 40-60 hours of week. We were shocked because we felt that physicians needed to be trained with this intensive sleepless experience. Perhaps, the reality is somewhere in between. Fatigue in quantitative trials by Kahol and his group adversely affects cognitive and psychomotor skills in trauma residents and attendings, but less so in the later. However, the fine motor skills become grosser with chunking in the trauma attendings. Many performance components decline with fatigue including gesture proficiency, too movement smoothness, and hand movement smoothness in addition to cognitive errors. I would assume that there are better outcomes with less fatigue as consequence of this. However, too much rest and not being prepared contributes. This is why the studies that Kahol and his group have shown using warm-up to improve performance are logical and useful. It is therefore, also not suprising that practice improves performance in the laboratory and at home with Wii systems. The problem is that to reach full "embodiment" requires simulation of the circumstances of surgery with noise and stress. If we can add more features of this, then training will become even more useful. Up until now, we have not incorporated these approaches into resident training or established surgical training and performance, much less incorporating this into the training of medical students. The old adage has been see one, do one, and teach one. This is how I learned to do a lumbar puncture on patients. I became pretty good at it, but what if I had had the approach and training provided by Kahol? As a further note, an integrated group of monitoring evaluations include EEG and skill analysis systems that use Bayesian classifiers and Hidden Markov models. In Neurology, we consider the EEG to be a crude tool that may have some relevance in capturing vigilance in these particular circumstances. This work would profit from incorporation of more precise indicators of physiological function as part of the studies. As such, it would be wonderful to use techniques like functional MRI or PET scan in these studies, not only for localization of function with training but also change with training. These techniques are not necessarily simple or feasible for this, but it would be useful to know of other measures to use in addition to EEG.

Posted by  Stuart