AUA2023 BEST POSTERS The INFLOW-OPERA Study: Investigation of Flow State Occurrence During Surgical Performance with Electroencephalography

By: Uwe Bieri, MD, University Hospital Zurich, University of Zurich, Switzerland; Melanie Baumgartner, MSc, University of Fribourg, Switzerland; Anne-Raphaëlle Richoz, PhD, University of Fribourg, Switzerland; Daniel Eberli, MD, PhD, University Hospital Zurich, University of Zurich, Switzerland; Cao Tri Do, PhD, University of Zurich and ETH Zurich, Switzerland; Cédric Poyet, MD, University Hospital Zurich, University of Zurich, Switzerland | Posted on: 30 Aug 2023

Study Need and Importance

The “flow” state, characterized by optimal focus and complete absorption in a task,¹ has been found to predict performance outcomes in various domains such as competitive sports and among professional musicians.^2,3 Brain-computer interfaces and heart rate (HR) sensors offer approaches to distinguish the flow state using electroencephalography (EEG) and HR: individuals who perform significantly better in tasks and experience flow show increased theta activity (4-7 Hz) in their EEG spectrum and lower HR.^4-7 Performance outcome is crucial in surgery, and achieving flow could significantly enhance physicians’ performance. However, no study has yet measured flow state and its bio- and neuromarkers during surgical tasks with the da Vinci Skills Simulator for robotic-assisted surgery. Our study aimed to investigate these markers during virtual reality (VR) operation training to provide objective measurements of peak performance.

What We Found

We conducted a study with 20 urological surgeons using a wireless EEG headband (Muse 2) to record theta activity and a wireless HR sensor (Polar H10) to measure HR. The VR training was performed on the intuitive da Vinci Skills Simulator for robotic-assisted surgery. After completing the surgical tasks, we assessed subjective flow experience using the Flow Short Scale (FSS). Two VR tasks were performed on the simulator, and the survey was taken directly afterward. This procedure was repeated 3 times on 3 different days with each participant. Our primary objective was to investigate differences between high and low performers regarding their EEG output, HR, FSS scores, and level of professional experience. To test the different models, we conducted generalized estimating equations models (Wald test) due to nonnormally distributed data. Additionally, Spearman’s rank correlation was computed to detect associations between the variables.

We found that high performers had a significantly higher theta activity than low performers with W(2) = 7.29, P = .026. In addition, we observed a significantly lower HR among high performers than among low performers, with W(1) = 9.86, P = .007 (MD = 10.21, SD = 3.33). Furthermore, we detected a positive correlation between VR surgery scores and subjective flow experience within high performers with r(10) = 0.63, P = .048.

Limitations

In general, portable EEG technology has limitations in reliably capturing affective states and accounting for environmental noise. Artifacts from body and head movements during the simulator task were highly present but prevalent in both groups. Furthermore, the data quality of the wireless EEG devices and the stability of connections posed challenges. The Polar H10 HR sensor had limitations in measuring baseline HR. Personal factors like stress, sleep, and arousal were not controlled for. Also, the level of expertise, gender, and age compositions were not thoroughly evaluated. The FSS was evaluated only at the end of measurements, hindering the differentiation of subjective flow experience between exercises.

Interpretation for Patient Care

Our findings indicate that surgeons who achieved higher performance showed increased theta activity in their EEG spectrum and lower HR than surgeons with lower performance during VR surgeries. Our physiological data highlight the importance of a calm state as a predictor of better surgical performance outcomes. These results may lead to specific bio- and neurofeedback VR training protocols for surgeons to enhance their performance, accelerate the learning curve, and reduce their arousal level during challenging intraoperative situations. These trainings could in turn benefit patients’ health due to better surgical outcomes.

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