Technique

The five minutes before you scrub that change the case

The orthobro · 2026-08-17 · 6 min read

"Run the case in your head first" is the kind of advice that sounds like something an attending says instead of teaching you.

It turns out to have a trial behind it. And the trial is not the interesting part.

The evidence, briefly

Twenty novice surgeons were trained on a virtual reality curriculum, then randomised. Before each of five laparoscopic gallbladder operations, one group did thirty minutes of mental rehearsal. The other group watched an online lecture.

The rehearsal group scored higher on the quality of their performance. Not on one procedure — on all five.

A systematic review published this year pulled together twelve studies on mental practice in surgery and found the same direction throughout.

So the effect is real, and it is better evidenced than most things anyone tells you during residency.

Now the caveat, which is the same one as last week: these were novices, on simulators. Nobody has run this trial on a PGY-4 doing a real case at 2am, and the reason is obvious — you cannot randomise real patients to have their surgeon prepare badly.

The part nobody mentions

Here is where it gets genuinely useful.

A separate study sat down with nine expert surgeons and eleven novices and asked them how they prepare for a difficult case. Both groups prepare. They just prepare completely differently.

The novices built decision trees. They thought through the patient's history, the anatomy, and then worked through an analytical "if this happens, then I do that" branch for every complication they could imagine.

The experts did not do this. They started from their standard technique — the way they always do the operation, regardless of how complicated this particular one looked — and planned to deal with contingencies as they came up.

Read that again, because it is the opposite of what effort feels like.

The novice approach feels like better preparation. It is more thorough. It covers more ground. You can spend an hour on it and feel ready. And it is what less experienced surgeons do.

What the experts had instead, in the authors' description, was a richer mental image of how the operation would actually unfold. Not a longer list of branches. A clearer picture.

What that means for what you rehearse

If you are going to spend time running the case in your head, the evidence points at a specific way to spend it.

Rehearse the normal version. The standard steps, in order, the way this operation actually goes. Not the disaster.

Rehearse it as a picture, not a list. The trial that worked measured the quality of participants' imagery, and better imagery tracked with better performance. Seeing the field is doing the work. Reciting the steps is not the same thing.

Do not build the branching tree. That is the thing the more junior group did. It feels productive and it is not what separates the people who are good at this.

That last one is the hardest to accept at 6am with a case you are nervous about, because the anxiety wants a plan for everything.

A footnote your patients would like

The same technique has been tested on the other side of the drapes.

A meta-analysis of seven trials looked at patients recovering from total knee replacement who did mental simulation alongside standard physiotherapy. Their quadriceps strength improved. Their knee flexion improved. Their pain scores improved.

And — being honest about it — their walking speed did not, and their overall WOMAC score did not. Some outcomes moved, some did not.

Still. The thing you might do before the case is the same thing that helps them after it.

The five minutes

The trial used thirty minutes before every procedure. Nobody has tested five, and I am not going to pretend the number in the title comes from the literature — it comes from what you will actually do.

Thirty minutes is a research protocol. Five minutes standing outside the scrub sink, running the normal version of the operation as a picture, is the version that survives contact with an actual list.

The rehearsal only works on an operation you can actually picture. Which means it depends entirely on whether you know the steps, the positioning, and this attending's preferences well enough to see them — and that part is not rehearsal, it is having written it down when you had time.