Temporal Stress in the Operating Room: Brain Engagement Promotes Coping and Disengagement Prompts Choking

Objective: To investigate the impact of time pressure (TP) on prefrontal activation and technical performance in surgical residents during a laparoscopic suturing task. Background: Neural mechanisms enabling surgeons to maintain performance and cope with operative stressors are unclear. The prefrontal cortex (PFC) is implicated due to its role in attention, concentration, and performance monitoring. Methods: A total of 33 residents [Postgraduate Year (PGY)1-2 = 15, PGY3-4 = 8, and PGY5 = 10] performed a laparoscopic suturing task under self-paced (SP) and TP conditions (TP = maximum 2 minutes per knot). Subjective workload was quantified using the Surgical Task Load Index. PFC activation was inferred using optical neuroimaging. Technical skill was assessed using progression scores (au), error scores (mm), leak volumes (mL), and knot tensile strengths (N). Results: TP led to greater perceived workload amongst all residents (mean Surgical Task Load Index score + SD: PGY1-2: SP = 160.3 +/- 24.8 vs TP = 202.1 + 45.4, P < 0.001; PGY3-4: SP = 123.0 + 52.0 vs TP = 172.5 + 43.1, P < 0.01; PGY5: SP = 105.8 + 55.3 vs TP =159.1 + 63.1, P < 0.05). Amongst PGY1 -2 and PGY3 -4, deterioration in task progression, error scores and knot tensile strength (P < 0.05), and diminished PFC activation was observed under TP. In PGY5, TP resulted in inferior task progression and error scores (P < 0.05), but preservation of knot tensile strength. Furthermore, PGY5 exhibited less attenuation of PFC activation under TP, and greater activation than either PGY1-2 or PGY3-4 under both experimental conditions (P < 0.05). Conclusions: Senior residents cope better with temporal demands and exhibit greater technical performance stability under pressure, possibly due to sustained PFC activation and greater task engagement. Future work should seek to develop training strategies that recruit prefrontal resources, enhance task engagement, and improve performance under pressure.