Gary Hamill, EdD, describes recent research efforts to demonstrate the potential of physiologic self-regulation and imagery training strategies to increase psychomotor capacity and improve performance.
Performing a medical procedure requires a tremendous amount of psychomotor capacity - your head, hands, and the team with whom you are working have to share the same mental model, i.e., “be on the same page”, while simultaneously anticipating potential outcomes of your actions and planning the next steps to be taken. Few domains present such challenges.

Debilitating Effects of Stress and Anxiety

Stress and anxiety can severely compromise the mental and physical capacities of individuals and teams, ultimately inhibiting their ability to function at their highest level during challenging clinical situations. This occurs because stress and anxiety impair central executive processes, particularly when the task being performed is complex and demands constant attention.1  In addition to negatively affecting cognitive processes, there is a clear, negative impact that stress and anxiety can have on motor performance.  For example, trembling hands or tense muscles can greatly impair the ability to guide the use of an instrument or medical device, placing the patient at risk. Additionally, as reported by the Joint Commission, anxiety induced by high-stakes, emotionally-charged situations hurts team performance and contributes to disruptive behavior.2  Furthermore, poor behavioral skills, including ineffective communication and inadequate teamwork, underlie many errors and sentinel events as reported by the Institute of Medicine.3 Most recently, in the Journal of Patient Safety, the number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year and serious harm seems to be 10 to 20 times more common than lethal harm.4

Self-Regulation and Guided Imagery

Stress and anxiety are psychophysiological processes; therefore, to improve performance, psychophysiological solutions are needed. Using self-regulation techniques improves your ability to think clearly and re-orient to the procedure. Essentially, by being relaxed, you free up areas of your brain that help with your decision-making and ability to access your working memory and procedural knowledge. Furthermore, when you are relaxed, it can help improve your motor coordination and dexterity - you can feel the instruments in your hands better or are more sensitive to the feedback when touching the patient. While self-regulation attenuates the cognitive (worry, self-doubt, lack of concentration) and somatic (increased heart rate, respiratory rate, and muscle tension) components of the anxiety response, guided imagery serves as the muscle and mental primer for optimal performance. Increasingly, evidence suggests there is a functional equivalence between picturing yourself doing a task and actually performing it – meaning, that when you imagine yourself doing an activity, similar or complementary neural pathways are activated as if you were actually doing the activity.

Pilot Research to Improve Learning, Psychomotor Capacity, and Performance under Pressure

In response to these extremely compelling needs, in 2009, Ranjan Sudan, MD and this author began a study using self-regulation and guided imagery with medical students on their surgery rotation while working in the Surgical Education and Activities Laboratory at Duke University. The goals of the study were to improve procedural strategy and management of intra-operative stress. The subjects were novices and their physiological measures such as heart rate, respiratory rate, and skin conductance were measured while they performed simulated surgical procedures.
Study subjects demonstrated a 20% to 100% improvement while completing elements of the Fundamentals of Laparoscopic Surgery (FLS) curriculum (pattern cutting and peg transfer) and using Laparoscopic Cholecystectomy virtual reality training.  These results were presented at the 2011 American College of Surgeons Education Consortium.
For the FLS pattern cutting exercise, having  < 2 cm3 of excess material when cutting out the pattern is one of the criteria for certification. In this study, a subject without any experience with this procedure completed their baseline procedure in 9:25 minutes with > 2 cm3 of error.  After training with the guided imagery module, the subject performed the procedure the next day and completed it 2:52 minutes quicker with < 2 cm3 of error. For the peg transfer, a subject using guided imagery training after their baseline peg transfer exercise demonstrated reduced time for task completion (1:58 minutes quicker), no dropped pegs, and a lower mean heart rate.  The following image displays a subject’s physiologic data and their view of the operative field during the procedure. Descriptors under the image provide quantified outcomes between pre- and post-intervention consisting of physiologic self-regulation and guided imagery training.  For some of the subjects using the laparoscopic cholecystectomy simulator, specific quantitative measures included reductions in the numbers of clips used, blood loss, injury to patient, elapsed time on completion of the procedure, and lower subject heart rate. Qualitative responses and outcomes included improved procedure planning and increased relaxation.5
Diagram 1. Source: Duke Surgery Simulation Education and Activities Laboratory Study.
More information can be found on the Duke Surgery Surgical Education and Activities Lab website at the following link: (Augmenting Technical Skills Training through Application of Video, Neuro-feedback and Guided Imagery Training)

Pilot Research on Team Adaptation and Synchronization

Pilot research on the psychophysiological aspects of team performance optimization was conducted in August 2013 at the Center for Advanced Pediatric and Perinatal Education (CAPE) at Lucile Packard Children’s Hospital at Stanford University School of Medicine.
To better understand how patient care teams react to stress in high-pressure situations, subject physiological data such as heart rate, heart rate variability, and respiratory rate were recorded while performing a simulated neonatal resuscitation.  In addition to physiological data, the State Trait Anxiety Inventory, Teamwork Perception Questionnaire, video analysis, and technical performance outcomes were also used. This provided a 360° psychophysiological study of team performance.
Diagram 2. Source: Stanford CAPE Study.
Click on the following link to learn more about this project:

(Improving Psychomotor Performance of Patient Care Teams)

Two significant findings from this study included:
1) The ability to quantify, through heart rate and heart rate variability, a psychophysiological response to complex cognition and collaboration. For example, when providing chest compressions, one’s physiology will increase beyond the pure mechanical load of providing compressions because the life is on the line. Please see notes on the diagram below regarding chest compressions.  In some cases, with this very experienced team of subjects, there was a 5% to 10% increase over practice / baseline chest compression measures. With a less experienced team, the arousal due to cognitive load could be much higher consequently resulting in performance decrement which was described earlier in this article.
2) A psychophysiological “zone of optimal functioning” emerged during the procedure.  Please see notes on diagram regarding team synchronization.
Diagram 3. Source: Adapted from the Yerkes-Dodson Law. (; accessed 2013-9-1)
Source: Adapted from the Yerkes-Dodson Law. (; accessed 2013-9-1)

Summary of Findings

These results demonstrate the potential of physiologic self-regulation and imagery training strategies to increase psychomotor capacity and improve performance. In fact, using psychomotor analytics helps pinpoint opportunities for growth. For example, in the following diagram, as heart rate continues to escalate as a measure of arousal, subjects move out of their “zone of optimal functioning” resulting in performance decrement. When this is correlated with the procedural video and discussed during the debriefing, it is now more clear what needs to be further developed. In fact, it was noticed in the Duke study the subject could begin increasing their physiological arousal as they anticipated a limitation in a technique they may not need to use for a few minutes. Physiologic self-regulation and guided imagery can be used to expand trainees’ “Zone of Optimal Functioning” and make them more resilient to performing under pressure – concepts central to the science of learning.

Going Forward: Shared Mental Models

Strategy is a mental map of what you are going to do. Mental simulation or guided imagery is the primer for training the brain to accomplish complex tasks. Therefore, picturing in your mind’s eye how you move from one aspect of the patient’s care to the next will improve the mental and physical execution of the tasks. In turn, this augments your capacity for teamwork – knowing how and being able to help one another take care of the patient, as well as re-orient as a team in the event a new course of action is needed to deliver excellent patient care.
About the Author
Gary Hamill, Ed.D., is the senior research scholar at the Center for Advanced Pediatric and Perinatal Education (CAPE,, Packard Children’s Hospital at Stanford, Division of Neonatology, Department of Pediatrics Stanford University School of Medicine. Hamill specializes in human performance optimization and has helped professional, collegiate, and amateur athletes perform at their highest levels during competitive, stressful situations for two decades by incorporating psychophysiological training into their regimens. He has over 50 publications and presentations on peak performance and has interviewed numerous professional athletes including Super Bowl Most Valuable Players and NBA All Stars.
During the past five years, Hamill has translated and applied the science of Human Performance Optimization toward medical education and performance. He was a Consulting Associate at Duke Medical School in the Department of Surgery’s Surgical Education and Activities Laboratory where he collaboratively developed a curriculum to assist medical students in the management of intra-operative stress, allowing them to learn and execute surgical procedures more quickly and efficiently.
Through applications of simulation, team science, and psychoneuromuscular theory, he works with faculty, trainees, and hospital staff to improve performance in emergency situations. Through these advances in active learning, healthcare professionals will achieve improvement in situational awareness, adaptive expertise, medical decision-making and ultimately, patient care.
If you would like to learn more about Human Performance Optimization and the Peak Performance Research Consortium, contact Dr. Hamill at
1. Derakshan N, Eysenck M. Anxiety, Processing Efficiency, and Cognitive Performance. New Developments from Attentional Control Theory.  European Psychologist 2009;14(2):168-176.
2. The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. 2008(40):1-3. Accessed August 10, 2013.
3. Kohn LT, Corrigan JM, Donaldson MS. eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
4. James JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety. 2013; 9(3): 122-128.
5. Sudan R, Hamill, G. (2011, April) Augmenting Technical Skills Training through Application of Video, Neuro-feedback and Guided Imagery Training.  Poster Presentation at the meeting of the Education Consortium for the American College of Surgeons, Chicago, IL.