Our conversation picks back up with an article titled “Mental toughness in surgeons: Is there room for improvement?” This paper was published in the December 2019 issue of the Canadian Journal of Surgery and evaluates mental toughness among general surgery residents and staff surgeons using the Mental Toughness Index. The authors found that staff surgeons score significantly higher across all domains—including self-belief, attention and emotion regulation, optimism, buoyancy, and adversity capacity—than residents.

Survey data from three Canadian academic centers showed that although both groups use some techniques to manage stress, staff rely on these strategies more frequently, and both residents and staff express strong interest in further developing mental toughness skills. The study also identifies gender differences, with men scoring higher in attention and emotion regulation. The authors highlight the lack of formal mental toughness training in surgical education despite evidence from athletics and paramilitary fields supporting structured psychological skills training.

Then, from this month’s issue of the Journal of the Association for Surgical Education, we review an article titled “Do expert surgeons use mental skills to improve their surgical performance?” This study explores whether expert pancreaticoduodenectomy (Whipple) surgeons use mental skills during complex operations and how these strategies map onto known performance psychology frameworks. Through structured interviews with 15 internationally recognized high-volume surgeons, the authors found that all participants consistently employ cognitive techniques—including preoperative mental rehearsal, deep task focus, emotional regulation, maintaining situational awareness, and reframing unexpected events—to optimize performance under pressure.

Surgeons described entering a “flow-like” state during critical steps, relying on deliberate calmness, structured routines, and controlled breathing to manage stress and maintain precision. These mental skills closely parallel those used in elite athletes and high-stakes professions, suggesting that expert surgical performance is supported not only by technical mastery but also by refined psychological strategies. The authors argue that mental skills training could be formally integrated into surgical education to help trainees develop the cognitive tools that expert surgeons intuitively use.