ARTICLE IN PRESS

Surgery ■■ (2017) ■■–■■

Contents lists available at ScienceDirect

Surgery
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y m s y

Enhancing surgical performance by adopting expert musicians’

practice and performance strategies
Mei Rui, DMA, Jeffrey E. Lee, MD, Jean-Nicolas Vauthey, MD, and Claudius Conrad, MD, PhD *
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

A R T I C L E I N F O A B S T R A C T

Article history: Background. Surgery is a performing art—each surgical procedure is a live performance that has im-
Accepted 25 September 2017 mediate and irreversible consequences for both the performer and the audience. Surgeons operate with
surgical instruments, whereas musicians perform with musical instruments. Both perform in high-
stress, high-risk work environments, where small errors in motor performance or judgment can have
immediate negative consequences. While there is abundant literature on musical performance and their
impact on outcome, little similar research has been published in the field of surgery. We aimed at iden-
tifying expert musicians’ practice and performance strategies that may aid surgeons to enhance their
surgical performance.
Methods. In the study, 82 relevant English-language articles from 1974 to 2017 matched applicable search
terms. Nominal Group Technique was applied to identify 5 key domains that comprise important par-
allels between surgical and expert musical performance.
Results. The 5 key domains identified were: (1) extensive training and deliberate practice, (2) dexter-
ity and ambidexterity, (3) performance evaluation and competition, (4) performance-related injuries, and
(5) performance anxiety. We found focused and mindful training in motor performance, not perform-
ing immediately after a hiatus from practice, training to improve the precision and responsiveness of
the nondominant hand, continuous and critical self-evaluation, training in injury recognition and pre-
vention, and pharmacologic factors to be of utmost importance.
Conclusion. Critical parallels exist between surgical and expert musical performance that may improve
surgical outcomes by adopting musicians’ strategies for combating physiological and psychologic
performance-related issues. Raising surgeons’ awareness for this subject content may improve surgical
performance and patient outcomes, as well as help prevent occupational injuries. (Surgery
2017;160:XXX-XXX.)
© 2017 Elsevier Inc. All rights reserved.

Surgeons operate with surgical instruments, whereas musi-
cians perform with musical instruments. Historically, there have been
several eminent surgeon-musicians, including Herman Boerhaave
(1668–1738), Leopold Auenbrugger (1722–1809), Theodore Billroth
(1829–1894), Alexander Borodin (1833–1887), Albert Schweitzer
(1875–1965), and Boyd Neel (1905–1981), each of whom made land-
mark contributions to surgical science and humanity. It seems
intuitive that the ability of these surgeon-musicians to play an in-
strument likely enhanced their motor performance to facilitate their
expert surgical performance.
However, while parallels between surgical and expert musical
performance exist, there is a dearth of literature on how surgeons
could potentially adopt expert musicians’ practice and perfor-
mance strategies to improve surgical performance. We therefore
performed a structured analysis of the published literature on mu-
sicians’ practice and performance strategies that could help surgeons
to improve their motor performance in the operating room, improve
mental health and prevent musculoskeletal injuries.
Methods

PubMed was searched for English-language articles published

The University of Texas MD Anderson Cancer Center is supported in part by the
National Institutes of Health/National Cancer Institute under award number
P30CA016672.
All authors claim no conflicts of interest or disclosures.
* Corresponding author. MD Anderson Cancer Center, Division of Surgery,
Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University
of Texas, 1400 Pressler, Unit 1484, FCT17.5046, Houston, TX 77030, USA.
E-mail address: cconrad1@mdanderson.org (C. Conrad).
between 1974 and 2017 using the search terms “surgical perfor-
mance,” “surgical skill,” “surgeon hand dominance,” “surgeon
dexterity,” “manual ambidexterity,” “pianist dexterity,” “musician
deliberate practice,” “competition performance,” “musician mus-
culoskeletal health,” “surgeon musculoskeletal health,” “musician
hand injury,” “surgeon hand injury,” “musician performance anxiety,”
“surgeon performance anxiety,” “performance stage fright,” “surgical

https://doi.org/10.1016/j.surg.2017.09.011
0039-6060/© 2017 Elsevier Inc. All rights reserved.

Please cite this article in press as: Mei Rui, Jeffrey E. Lee, Jean-Nicolas Vauthey, and Claudius Conrad, Enhancing surgical performance by adopting expert musicians’ practice and
performance strategies, Surgery (2017), doi: 10.1016/j.surg.2017.09.011
 ARTICLE IN PRESS
2 M. Rui et al. / Surgery ■■ (2017) ■■–■■
Fig. Parallels between surgical and musical performance.
performance propranolol,” “musicians propranolol,” and other com-
binations of relevant terms. The reference lists of articles identified
in the searches were cross-reviewed by authors to identify addi-
tional relevant articles. Then the authors reviewed the identified
articles independently to (1) identify relevant articles, (2) extract
key parallels between surgical and musical performance, and
(3) collaboratively evaluate the information for relevance.
Nominal Group Technique to take each group member’s opinion
into account was applied. First, group members reviewed the lit-
erature independently and provided a list of key domains with their
supporting relevant literature. Duplicate musical domains were elimi-
nated by the facilitator. The facilitator encouraged discussion for the
naming and identification of domains to find the domain terms that
would encompass most of the relevant literature. For example,
domains such as “collaboration and team dynamics” and its paral-
lel “chamber music” were discussed, voted to be less relevant and
therefore excluded. The 5 domains with the highest ranking were
selected as the 5 domains under which the relevant literature was
grouped. Prioritizing the recorded domains pertaining to parallels
between musical and surgical performance were performed using
direct voting. Published articles on surgical performance and musical
practice guidelines and performance strategies were compared. The
data were synthesized to identify concrete practice and perfor-
mance guidelines that could aid surgeons in improving surgical
performance.
Results
A total of 82 relevant articles were identified. Five parallels were
identified between surgical and musical performance (Fig). To achieve
optimal performance, both expert surgeons and musicians may
benefit from (1) extensive training, deliberate practice, (2) ambi-
dexterity, and continuous performance evaluation. Both are
susceptible to (3) performance-related injuries, (4) performance
anxiety, and may draw on (5) pharmacologic measures, especially
the use of β-blockers, to alleviate symptoms. The extracted infor-
mation was discussed in a structured review process and the results
are presented below. After discussion of the data, each perfor-
mance item is followed by concrete recommendations on how to
use the information from expert musical performance to improve
surgical performance.
Movement I: extensive training and deliberate practice
Surgical and musical performance both require extensive train-
ing and deliberate practice to achieve and maintain expertise.1-5
Deliberate practice is a mindful, structured, repetitive, and reflec-
tive process that demands relentless self-critique, and error detection.
An estimated minimum of 10 years of intense involvement and
10,000 hours of deliberate practice to achieve mastery in highly
Please cite this article in press as: Mei Rui, Jeffrey E. Lee, Jean-Nicolas Vauthey, and Claudius Conrad, Enhancing surgical performance by adopting expert musicians’ practice and
performance strategies, Surgery (2017), doi: 10.1016/j.surg.2017.09.011
competitive fields such as surgery and classical music is required.3,6
For most surgeons, completion of surgical training requires 5 to 10
years—equivalent to ≈10,000 hours—of total-immersion training.
Similarly, a graduate-level, professional pianist also will have ac-
cumulated ≈10,000 hours of practice, while an amateur one of
comparable age will have practiced only 2,000 to 8,000 hours.7 A
study on surgical residents showed that deliberate practice, com-
pared with standard training alone, led to higher-quality laparoscopic
surgical performance as measured by speed, dexterity, and global
rating scales.8 Recently, educational initiatives have been imple-
mented to accelerate the “training to competence” process and
decrease hours spent in surgical training.9 Whether this can actu-
ally be accomplished successfully is an area of ongoing research.10,11
Furthermore, the importance of deliberate practice may extend
beyond surgical trainees to staff surgeons in practice: low operative
volume institutions have significantly higher 90-day mortality and
lower-quality oncologic surgery for patients undergoing laparoscopic
pancreaticoduodenctomy.12 Insufficient “practice time” in perform-
ing this complicated procedure is almost certainly a major factor.
Among musicians, it is a well-regarded principle that consis-
tent deliberate practice contributes to performance success, while
paucity or interruption of practice has a deleterious effect on per-
formance quality. Various studies have shown that productivity is
reduced when the temporal distance between tasks increases.13,14
In 188 surgeons who performed 56,315 coronary artery bypass graft-
ing surgeries, each additional day away from the operating room
increased the inpatient’s mortality rate. Among the subgroup of
emergent patients treated by high-volume providers an addition-
al day away raised mortality risk by 0.398 percentage points (11.4%
relative effect). For surgeons needing to intervene in patients
emergently, as temporal distance increases, the ability to recog-
nize and address life-threatening emergent complications decreases.
Absence from the operating room for 3 to 14 days before surgery
raised the mortality risk by 11% to 14% (relative effect), and absence
for >15 days raised the mortality risk by 22%.15 While it would be
unimaginable for a concert violinist to vacation without practic-
ing on their instrument in the days leading up to an important
concert, surgeons may elect to perform challenging operations the
day after returning from a trip, resulting in compromised surgical
outcomes.
Recommendations for surgeons
Data on deliberate practice suggest that reduction in surgical
trainees’ work-hours can compromise mastery of surgical motor and
patient management tasks.10,11 Therefore, to compensate for the de-
creased hours spent in the operating room, surgical simulation,
focused training in motor performance, and earlier specialization
to reduce dilution of training may be beneficial. Moreover, sur-
geons should consider avoiding scheduling high-risk operations
immediately after returning from a surgical hiatus lasting for ≥3 days.
Movement II: dexterity and ambidexterity
Surgical performance and musical performance both require
high levels of dexterity in both the dominant and the nondominant
hand. Surgeons routinely need to use their nondominant hand to
facilitate surgery—to support anatomic structures or to optimize the
angle of dissection. A previous study showed that using the
nondominant hand to operate required 1.45 times as long as using
the dominant hand,16 suggesting an asymmetry in dexterity between
the dominant and nondominant hands. Other recent studies re-
vealed high bimanual dexterity as a predictor of expert surgical
performance,17 and a trend toward improved navigation and bi-
manual performance with daily training of the nondominant hand
using designated activities, such as playing video games.18
 ARTICLE IN PRESS
M. Rui et al. / Surgery ■■ (2017) ■■–■■
Numerous studies have demonstrated the superb dexterity of mu-
sicians’ hands,19 and the greater agility in the nondominant hand
compared to nonmusicians.20 From an early age pianists receive ex-
tensive bimanual training, which has been shown to even out the
inherent asymmetry of the hands through technical drills consist-
ing of etudes composed for the nondominant hand.20 Further,
neurologic correlates have been associated with these physical find-
ings: whereas nonmusician controls have a pronounced left-larger-
than-right asymmetry in the intrasulcal length of the precentral
gyrus, which correlates with the size of the primary motor cortex,
pianists exhibit significantly more symmetry between left and right
intrasulcal length of the precentral gyrus.21 The proposed mecha-
nism for this greater symmetry in musicians is functionally induced
plasticity and long-term structural adaptations in the human motor
cortex as a result of extensive training.
Other studies have highlighted the plasticity of the nondominant
hand in both musicians and nonmusicians after amputations.22,23
After losing his right arm during World War I, the eminent pianist
Paul Wittgenstein (1887–1961), to whom Ravel dedicated his Piano
Concerto for the Left Hand, became a celebrated left-handed concert
pianist.24 Alexander Scriabin, a right-handed pianist and composer
who endured chronic right-hand pain, altered his piano composi-
tions to adapt to the physical imbalance between is hands.25 In this
context, it has been shown, that surgeons, playing a musical in-
strument and/or video games may improve surgical dexterity and
suturing skills of the nondominant hand.26-28
The above data suggest that nondominant hand dexterity can
be enhanced through extensive training. An approach frequently
used in stroke patients to improve neural plasticity and motor
performance involves targeting the primary motor cortices with
bihemispheric noninvasive transcranial direction current stimula-
tion (tDCS),29 a noninvasive brain-stimulating technique.30,31 Among
musically untrained control subjects, tDCS improved fine motor
control in both hands, especially the nondominant hand.32 More in-
terestingly, another study demonstrated that the older the pianists
started their musical training, the more they benefited from tDCS.33
Future research is needed to investigate tDCS for ambidexterity-
optimization for surgeons with particularly reduced performance
of their nondominant hand.
While technological innovations like robotic and laparoscopic sur-
gical platforms can help overcome innate hand dominance34 through
superior ergonomics, greater magnification and improved tremor
filtration, many procedures require direct manual manipulation. Due
to the scarcity of data documenting the effect of handedness on sur-
gical outcomes, investigations in this under-researched area are
necessary to understand how ambidexterity may impact outcomes
and how surgeons with below-average ambidexterity can be iden-
tified and trained to improve performance of their nondominant
hand.
Recommendations for surgeons
On the basis of the aforementioned data, we recommend that
surgical trainees be considered for testing for the degree of inher-
ent asymmetry between the dexterity of the dominant and
nondominant hands. Those with the largest disparity should have
the opportunity to undergo task-specific training to improve the pre-
cision and responsiveness of their non-dominant hand. tDCS may
be further investigated to determine whether it may improve sur-
gical dexterity of the nondominant hand.
Movement III: performance evaluation and competitions
To become professional surgeons and musicians, apprentices in
both fields go through numerous competitions and examinations
to have their skills evaluated by experts. While musicians competing
Please cite this article in press as: Mei Rui, Jeffrey E. Lee, Jean-Nicolas Vauthey, and Claudius Conrad, Enhancing surgical performance by adopting expert musicians’ practice and
performance strategies, Surgery (2017), doi: 10.1016/j.surg.2017.09.011
3
for an orchestral position inevitably must undergo live perfor-
mance auditions, surgical trainees are commonly not evaluated for
their technical or performance skills (surgical performance under
pressure) when applying for a training program.
Although sound has traditionally been valued as the only factor
in judging performance quality in the field of music,35 studies
have confirmed the critical impact of visual information on the au-
dience’s evaluation of musical performances—a phenomenon
referred to as the Colavita visual dominance effect.36 In one study,
professional and novice musicians alike consistently rated silent
video recordings of performances by the winners of international
piano competitions more favorably than those of less successful
competitors.37 Another study showed that orchestral conductors’
skills were rated accurately on the basis of the visual cues con-
veyed through their conductive gestures alone.38 These studies
collectively suggest the importance and reliability of evaluating
musical performance from visual cues only.
In the field of surgery, it is intuitive that the technical aspects
of surgical performance can be assessed visually. Furthermore, by
watching videos of surgical performance, surgeons can not only ac-
curately assess their peers’ laparoscopic skills, but also even estimate
their peers’ risk-adjusted postsurgical complication rate.39 This sug-
gests that videos should be more commonly utilized for evaluating
surgeons’ performance. Researchers also have tested whether having
a large number of reviewers judge surgical performance on the basis
of videos alone (a “crowdsourcing” approach) is a valid alterna-
tive to expert evaluation for assessment of surgical skills.40-45 These
studies analyzed the ratings of viewers who judged short (2–10
minutes) videos showing dry laboratory, wet laboratory, robotic
surgery, and suturing skills (range: 548–2,027 raters per video). The
results of these studies demonstrated that crowdsourcing can serve
as a low-cost tool for evaluation of psychomotor surgical skills,
especially in resource-poor environments.
Another important method of judging surgical performance is
self-evaluation. Despite its inevitably biased nature, self-evaluation
is an indispensable tool for achieving and maintaining expertise.
It has been demonstrated that surgical residents’ evaluation of their
own skills was more critical than that of their attending surgeons.46
Interestingly, the residents most critical of their own performance
were also the highest performing ones,46 suggesting that critical self-
evaluation correlates with better surgical performance.
An additional evaluative method adopted by musicians to hone
and test their performance expertise, but is noticeably absent in the
field of surgery, is partaking in competitions. While there is cur-
rently no surgical competition designed to identify exceptional
surgical skills and talent, it has been shown that a healthy com-
petitive environment enhanced surgical performance and fostered
strong interaction among novice surgeons,47,48 even among the par-
ticipants who declared to not be motivated by competition.49
When not participating in competitions, musicians evaluate their
own performance by reviewing and critiquing recordings of their
own rehearsal and practice sessions for self-improvement. Simi-
larly, a study of orthopedic surgical residents showed that reviewing
intraoperative videos of their own performance improved their or-
thopedic surgical skills training.50 Finally, the learning method of
reviewing prerecorded videos may be especially beneficial when
it comes to low-volume procedures, for example, as has been shown
for forceps-assisted deliveries.51
Recommendations for surgeons
Surgeons can benefit from studying exemplary videos of spe-
cific procedures performed or to be performed, and from a supportive
but competitive training environment. Low-cost crowdsourcing may
be an innovative way of reviewing surgical performance in resource-
deprived environments. Furthermore, novice and experienced
 ARTICLE IN PRESS
4 M. Rui et al. / Surgery ■■ (2017) ■■–■■
surgeons alike can benefit from having their skills evaluated and
monitored by their peers, and even more importantly, improve sur-
gical performance through continuous, critical self-evaluation.
Movement IV: occupational injuries
Preserving a healthy body unburdened by pain or injury plays
a pivotal role in sustaining the longevity of surgical and musical
careers. To meet the high demands of a performance career, pro-
fessional pianists practice 3 to 5 hours a day,1 comparable with the
21 hours per week median operative time for surgeons.47 Contra-
dicting the common notion that most occupational injuries can be
attributed to cumulative “wear and tear” from daily practice, studies
have failed to correlate neither higher age or more years of expe-
rience with an increased risk of injuries.47 These data suggest that
it is how, not how much, one moves that determines his or her risk
for performance-related problems.
Previous work has shown that professional pianists use their
hands in a more ergonomic and efficient manner than amateur pia-
nists do.48 Compared with amateurs, expert pianists perform with
lower-energy-cost movements, greater degrees of freedom in their
hands and arms, and less muscular force. They use pivoting tech-
niques and flexible movement organization, and cluster disparate
gestures to maximize movement efficiency.33 Additionally, they gen-
erate rapid motion from more proximal parts by using wrist rotation,
which helps alleviate and dissipate tension in the arms.52 Adopt-
ing these aforementioned techniques may help surgeons maintain
the musculoskeletal health of their hands and extend the longev-
ity of their career.33
However, even the most movement-conscious musician can have
performance-related fatigue, pain, and injuries from chronic and ex-
haustive use of their hands and arms.53-55 Similarly, even the most
anatomy-conscious surgeons are prone to operation-related fatigue,
pain, and injuries. A study on gynecologic surgeons showed that
musculoskeletal fatigue and pain were highly prevalent, with women
being affected twice as often as men.56 Another study on orthope-
dic surgeons found that two-thirds of respondents had a work-
related musculoskeletal disorder.57 Despite the comparably high
prevalence of occupational injuries in both professions, our inves-
tigation revealed striking differences in responding to them at a
personal and institutional level.
A comprehensive study of 4,025 professional musicians showed
that when confronted with hand, arm, or neck pain associated with
playing their instrument, few would hesitate to seek immediate pro-
fessional help, and most would consider a hiatus from playing.58 To
address the prevalence of performance-related injuries among mu-
sicians and their coaches, the National Association of Schools of
Music mandates that all conservatories include injury prevention
and awareness in their curricula.59
In contrast, surgeons are more reluctant to address physical
impediments openly and obtain necessary treatment. This disin-
clination can be partially attributed to innate personality differences
between surgeons and the general population.60 A study from the
Massachusetts General Hospital demonstrated that surgeons re-
covering from a hand or wrist fracture chose to return to their
operative duties well ahead of the schedule set by their hand sur-
geons (average elected return to work 25 days after surgery).61 A
survey of 260 surgeons found that 40% had sustained injuries at their
workplace and 53% of injured surgeons reported that the pain from
musculoskeletal injuries had a noticeable effect on their surgical per-
formance. More alarmingly, while 50% of injured surgeons received
medical care, only 20% of injured surgeons reported their injuries
to the institution.50 Another study of 140 orthopedic surgeons con-
cluded that only 25% of injuries were reported to the institution,
while 38% of injured surgeons declared that insufficient institu-
tional resources were available to meet their recovery needs.62
Please cite this article in press as: Mei Rui, Jeffrey E. Lee, Jean-Nicolas Vauthey, and Claudius Conrad, Enhancing surgical performance by adopting expert musicians’ practice and
performance strategies, Surgery (2017), doi: 10.1016/j.surg.2017.09.011
Left untreated, hand injuries can severely impact a surgeon’s job
satisfaction,62 curtail his or her surgical career, compromise patient
safety, decrease productivity, and increase medical costs to the
institution.50 Therefore, it is important to train surgical residents to
recognize early symptoms of operation-induced fatigue and pain,
properly warm up before and cool down after long operations, and
adopt preventative and therapeutic strategies to protect the long-
term health of their hands. To help foster open discussions and
eradicate the stigma associated with hand tremors and pain among
surgeons, wellness and integrative medicine centers should active-
ly engage surgeons to participate in wellness programs that are
routinely offered, including yoga, Alexander techniques, medita-
tion, and on-site massage therapy.
Recommendations for surgeons
Training programs for surgeons should include movement-
conscious injury prevention in their curricula. Surgeons and trainees
should vigilantly monitor their own physical condition and take
prompt measures to minimize operation-induced musculoskel-
etal fatigue and injuries. Moreover, we recommend that institutions
allocate sufficient resources to meet the treatment and recovery
needs of injured surgeons and trainees; and create workshops that
promote the prevention, recognition, and treatment of surgeons and
trainees’ workplace injuries and recovery from such injuries.
Movement V: performance anxiety and β-blocker usage
Both surgery and live musical performances are challenging on
physiologic, emotional, and intellectual levels. Given the high-
pressure, immediate nature of surgery or a live musical performance,
surgeons and concert musicians routinely experience acute situ-
ational (state) stress and performance anxiety, which manifests
through an inflammatory response.63 A biologic correlate has been
found among orchestra musicians, in whom key inflammatory
markers, including interleukin-6 and C-reactive protein, were found
to be significantly elevated during live performance compared with
rehearsal.63 Although a small increase in stress hormones can in-
crease alertness and task efficiency, excessive levels of stress
hormones can significantly compromise cognitive efficiency, atten-
tion, concentration, and motor skills.64
Surgeons and musicians have both resorted to pharmaceutic in-
terventions to combat performance anxiety and/or enhance
performance. Two studies found that 19.9% of 1105 German sur-
geons and 10% of top-ranked German chess players surveyed in 2017
(another cohort that has a high-stress work environment) have
reported using cognition-enhancing drugs.65,66 As for the 2,212 mu-
sicians surveyed in a national study of orchestral musicians in 1988,
20% of them—similar percentage to the surgeons surveyed—
admitted to using β-blockers prior to public performances60 to
combat performance anxiety.
Musical performance anxiety, also known as stage fright, can
cause hyperhidrosis, hyperventilation, and debilitating hand
tremor.67 Musical performance anxiety was found to be the leading
nonmusculoskeletal medical problem. A 2012 study concluded that
1 in 3 orchestral musicians has severe performance anxiety during
live performances.68 A combination of situational factors and cir-
cumstantial variables increases the risk of musical performance
anxiety, including solo (versus group) performance,69 evaluative
(with a jury) versus nonevaluative (without a jury) performance,70,71
and public performance versus private practice.72 An operation is
inevitably a solo, evaluative, and public performance. Today, there
is limited research on surgeons afflicted with surgical performance
anxiety.
The most debilitating of the three main physiologic manifestations
of musical performance anxiety—hyperhydrosis, hyperventilation,
 ARTICLE IN PRESS
M. Rui et al. / Surgery ■■ (2017) ■■–■■ 5

and hand tremor—is physiologic hand tremor, which are high-
frequency (6–12 Hz), low-amplitude (<1 mm) oscillations caused by
a sympathetic, somatic mechanism.73 Because of the high demand
for dexterity and complex finger-movement coordination when
playing a musical instrument—for example, certain piano works
require 11.5 keystrokes per second33—even the minutest tremor can
negatively impact performance precision and accuracy. Analo-
gously, hand tremor can have a detrimental impact on surgical
precision and patient outcomes, especially in microsurgical
procedures,74 during which even the smallest amplitude of tremor
can cause significant errors. Notably, a surgeon’s experience has not
been shown to play a role in the frequency and magnitude of phys-
iologic hand tremor.75
Studies have shown that physiological tremor can be mitigated
by low doses (10–40 mg) of the β-blocker propranolol.76 Unlike
other substances consumed for relaxation, including alcohol and
benzodiazepine medications, propranolol does not impair higher
central nervous system functions.77 A study on musicians showed
that the β-blockade mechanism completely eliminates the physi-
cal hindrances to performance caused by stage fright, including
uncontrollable tremors, sweaty palms, hyperventilation, and dry
mouth. Remarkably, the performance quality of musicians who had
taken β-blockers was judged to be significantly superior to that of
the nonmedicated group by experienced music critics.78
Whereas there is an abundance of data highlighting the
performance-enhancing and nontranquilizing effect of proprano-
lol, there are only a few studies of propranolol’s effects on surgeons
who are prone to having physiologic symptoms of operational
anxiety. However, a double-blind, randomized study found that ad-
ministering 40 mg of propranolol to surgeons 1 hour before surgery
significantly increased surgical performance and decreased anxiety
and hand tremor without unintended effects for the surgeon or
patient.73
In addition to physiologic stress and anxiety, preventable causes
of hand tremors may include fasting, sleep deprivation, fatigue due
to physical or mental exertion, dehydration, and excessive inges-
tion of caffeine.79-82 Preoperative caffeine use has been found to
increase change-from-baseline tremor measurements by 31%.81 While
some surgeries may be little affected by a tremor, for those that are,
these studies suggest that in addition to refraining from caffeine use
and fasting prior to surgery, the use of β-blocking agents (10–40 mg
of propranolol 1 hour prior to surgery) may reduce physiologic hand
tremor and improve overall surgical performance and patient
outcomes.
Recommendations for surgeons
The data above suggest that to minimize hand tremor, sur-
geons may benefit from refraining from fasting, sleep deprivation,
fatigue due to physical or mental exertion, dehydration, and ex-
cessive ingestion of caffeine prior to surgery. Additionally, surgeons
and trainees performing minimally invasive and micro surgeries,
and having uncontrollable intrasurgical hand tremors or perfor-
mance anxiety, may benefit from the use of β-blocking agents.
Coda/Conclusion
In this review, we have identified 5 key parallels between sur-
gical performance and musical performance (Fig), and provided
key recommendations to surgeons that may enhance surgical per-
formance and potentially improve patient outcomes (Table). In
summary, our examination of the existing literature on surgical and
musical performance has led us to conclude that both professions
demand serious commitment to extensive training and deliberate
practice and a high level of ambidexterity. Furthermore, surgeons
may improve surgical outcomes by adopting expert musicians’ strat-
egies for combating physiologic and psychologic performance-
related issues by using deliberate practice to enhance concentration
and error-detection through reflective feedback. Avoiding sched-
uling complex, high-risk operations the day after returning from a
surgical hiatus that lasted for ≥3 days may aid in improving patient
outcomes. Taking conscious measures to improve dexterity of the
non-dominant hand will improve operative performance. Engag-
ing in continuous peer- and self-evaluation is a low-resource
approach that has been shown to help foster a culture of learning
and technical perfection. Recording surgeries, especially low-
volume procedures, and reviewing them for self-critique and self-
improvement should be a routine measure for improving surgical

Table
Recommendations for improving surgical performance based on strategies adopted by expert musicians.

Recommendations for improving surgical performance based on strategies used by expert musicians

Performance issue Musician’s approach Recommendation for surgeons

Achieving technical virtuosity and
consistency
Time-away from practice and
performance
Unbalanced control of the dominant and
nondominant hands
Performance plateau and
self-complacency
Need for private feedback, self-critique
and self-improvement
Need for out-of-comfort-zone, public and
evaluative judgment and recognition
Musculoskeletal injury prevention
Musculoskeletal injury treatment
Hand tremor not related to
performance anxiety
Hand tremor related to performance
anxiety
Deliberately practice for 10,000 + hours. and extensive training
for 10 + years.
Adopt specific exercises to strengthen weak technical areas.
Avoid scheduling concerts immediately after being away from
consistent and structured practice.
Practice special scales, arpeggios, and etudes to improve the
independence and strength of the nondominant hand.
Receive regular, scheduled coachings and masterclasses with
teachers and peers.
Record practice sessions and rehearsals for self-critique and
self-improvement purposes.
Participate in regional and international auditions and
multiround competitions.
Practice mindfulness, yoga, Alexander techniques, meditation,
and get massage therapy to help prevent, stabilize, and heal
injuries.
Recognize early signs of performance-related injuries, and do
not hesitate to seek immediate medical help.
Avoid fasting, sleep deprivation, strenuous physical or mental
exertion, dehydration, and excessive ingestion of caffeine prior
to important performances.
Administration of 10 to 40 mg of propranolol 1 hour prior to
concert to reduce hand tremor.
Use deliberate practice to enhance concentration and
error-detection through reflective feedback, and partake
in virtual-reality training for task-specific training.
Avoid scheduling complex, high-risk operations the day
after returning from a surgical hiatus lasting ≥3 days.
Consider transcranial direction current stimulation to
improve the dexterity of the nondominant hand.
Have skills regularly evaluated and monitored by peers
and engage in continuous self-evaluation.
Record surgeries, especially low-volume procedures, and
review them for self-critique and self-improvement
purposes.
Participate in surgical performance competitions for
novice surgeons.
Practice mindfulness, yoga, Alexander techniques,
meditation, and get massage therapy to help prevent,
stabilize, and heal injuries.
Learn to recognize early signs of surgical occupational
injuries, and seek immediate medical help.
Avoid fasting, sleep deprivation, strenuous physical or
mental exertion, dehydration, and excessive ingestion of
caffeine prior to operating.
Consider administration of 10 to 40 mg of propranolol
1 hour prior to surgery to reduce hand tremor.

Please cite this article in press as: Mei Rui, Jeffrey E. Lee, Jean-Nicolas Vauthey, and Claudius Conrad, Enhancing surgical performance by adopting expert musicians’ practice and
performance strategies, Surgery (2017), doi: 10.1016/j.surg.2017.09.011
 ARTICLE IN PRESS
6 M. Rui et al. / Surgery ■■ (2017) ■■–■■
skill. A supportive but competitive training environment that fosters
mastery of surgical performance may help trainees to judge their
surgical motor skills relative to the skills of their peers and create
a desire to improve. Training programs should include in their cur-
ricula tips for recognizing early signs of surgical occupational injuries.
Hospitals should advise trainees and staff surgeons to seek imme-
diate medical help when repetitive motion injuries occur. Practicing
mindfulness, undergoing massage therapy, and engaging in active
relaxation with yoga or Alexander techniques can help prevent, sta-
bilize, and heal injuries. Avoiding fasting, sleep deprivation, strenuous
physical or mental exertion, dehydration, and excessive ingestion
of caffeine prior to a complex surgical procedure can reduce hand
tremor. When surgeons or surgical trainees have performance anxiety
that results in detectable intra-surgical hand tremors, the admin-
istration of β-blocking agents prior to surgery may reduce hand
tremor. Further investigation is needed to establish the role of cog-
nitive enhancing pharmacologic agents to combat performance
anxiety and improve technical performance.
This study has several important limitations: many of the primary
data are derived from retrospective and observational studies, which
are at risk for selection bias. Another limitation is that the study
includes a nonexhaustive limit of the 5 most relevant domains, and
that meta-analytical tools could not be applied due to the number
and quality of publications on this topic. Nevertheless, as much struc-
ture as possible was given to the selection process of relevant
domains and included publications using Nominal Group Technique.
Furthermore, while this article is focused on operative perfor-
mance, excellence as a surgeon depends on other factors including
interpersonal intelligence, personality, decision-making, and com-
passion among others, which were not the focus of this study.
Nevertheless, as surgeons are ultimately called upon to perform
surgery, technical prowess is as essential to the construct of an ex-
cellent surgeon as virtuosity is to the makings of a master musician.
Because musicians devote a significant portion of their training and
professional career to technical refinement and maintenance—
even eminent virtuosos like Sergei Rachmaninoff religiously practiced
daily technical drills for hours throughout his career—they may be
well qualified to share these general concepts with surgeons for
whom technical command is an essential contributor, aside from
many others, to their professional success. Additionally, while this
article focuses on the similarities between surgical and expert
musical performance, important differences (e.g., excellence in sur-
gical decision making or patient-surgeon interaction) have not been
discussed.
Surgery is a performing art. Each surgical procedure is a unique
live performance that has immediate and irreversible conse-
quences for both the performer and the audience. Whereas a subpar
musical performance may earn the musician an unfavorable review
and potentially derail his or her concert career, an unsuccessful
performance in the operating room can have life-threatening
consequences for the patient. We posit that having surgeons an-
ticipate and address performance issues as comprehensively and
as thoroughly as musicians do will improve surgeons’ skill and may
improve surgical outcomes and patient safety.
Acknowledgment
We thank Nicholas Navin, PhD, and Stephanie Deming, B.A.
(Bachelor of Arts), for their editorial support.
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