Achieving Cognitive Dominance in Spine Surgery

A neurosurgeon's quest to out-think fear.

Peer Reviewed

Neurosurgeon Mark McLaughlin, MD, has developed a framework to help surgeons recognize and constructively wrestle with feelings of anxiety and fear that can arise during complicated spine surgeries, as well as other situations in life. In his book, Cognitive Dominance: A Brain Surgeon's Quest to Out-Think Fear, Dr. McLaughlin uses his 28 years of experience as a brain and spine surgeon to outline a strategy for enhanced situational awareness that facilitates rapid and accurate decision-making under stressful conditions with limited decision-making time.

Dr. McLaughlin is the founder of Princeton Brain, Spine, and Sports Medicine where he practices surgery focusing on trigeminal neuralgia and cervical spine surgery.

Cognitive Dominance book cover

What was the impetus for writing your book?

Dr. McLaughlin: I was a philosophy major in college and have always believed the humanities and sciences fit together. During my career as a neurosurgeon, I have always tried to find meaning in the sometimes seemingly senseless cases of suffering that we see as physicians, whether it is a patient with terrible pain who does not respond to surgery or has incurable cancer.

Similarly, I have tried to make sense out of my high anxiety experiences as a surgeon. What I identify as fear during difficult surgeries, other surgeons may call anxiety or feeling uncomfortable. To me, all of those feelings are subtle shades or gradients of fear.

While writing and thinking about this book, I developed a formula (or map) to deal with fear. I realized that this formula was transferable to other areas of life and helped me get through tough times. In my book, I describe how I’ve applied this framework to help see the world more clearly during different fearful life experiences, including surgery.

man in a storm changes his perspectiveGetting a grip on a fearful situation can change your perspective. Photo Source:

How can SpineUniverse readers practice cognitive dominance?

Dr. McLaughlin: First, I present a Cartesian four-quadrant graph that readers can use to identify their psychological state when an unexpected event occurs that causes fear. These quadrants include the following:

  • Flow
  • Calm before the storm
  • All is lost
  • Birth of a new skill set

For example, the calm before the storm quadrant is where you are experiencing something that you didn’t expect and you’re not feeling the way you thought you might. The all is lost quadrant is when you’ve done everything you possibly could and something bad still happens. Taking a moment to identify where you are on that map will help you identify the nature of the obstacle you are faced with and how to get through it.

In addition, I present different techniques surgeons can use to practice cognitive dominance. For example, the PGR rule (named after my grandfather Dr. Pizzi, professor Enrique Gerszten, MD, and patient Rob Conenello) states that when you feel like all is lost, come up with multiple levels of looking at the event to see what you might be missing. For example, what are three things not included in the differential diagnosis that could be missing? Lateral thinking is essential to surgery because when we are set on pattern recognition, which is common when we are sleep deprived, we might miss something.

Another technique called IRISE is good for catastrophes and orients your brain to evaluate the situation rationally instead of acting out of fear. It is a mental exercise that involves taking a pause to Identify the situation and Reject your initial gut response to respond immediately out of fear. Instead, take Inventory of the tools available to combat uncertainty from a macro level and find out if anybody else in the room has experienced the same situation. Next, Stabilize by making sure patient vital signs and critical indicators are taken care of first to buy time and allow yourself to think. And, finally, Evaluate the problem analytically and use the PGC rule to think laterally.

Can you give an example of how you overcame a spine surgery-related fear?

Dr. McLaughlin: About 5 years into my career, I was operating on a tumor around C1-C2. I expected a smooth tumor capsule and clean tissue plane. But what I encountered once I got down to the tumor was that it was densely adherent to the brainstem. After a few preliminary attempts to shave this monster off failed, I got spooked. For a split second I became unnerved… more than unnerved… bordering on panic. What was I going to do? I thought, if I don't dissect this tumor off perfectly, this person could have locked-in syndrome or Ondine’s curse, where injury to the brainstem causes patients to stop breathing every time they fall asleep.

For a moment I thought, “you took on too much here. You should’ve sent this case to a more experienced doctor.” It was an internally terrifying moment or two. Then, I got my wits back and said to myself, “Wait a minute. You’ve trained your whole life for this. You completed 7 years of neurosurgery residency another year of spine fellowship and have been in practice for 5 years. There is nobody who can do this better.”

Getting my head back into the surgery, I turned to an old mental mantra from residency: “Get around it, shrink it, remove it.” Saying this over and over again in my head helped me surround the tumor, take its blood supply, and after getting a little victory here and there, ultimately removing it. When you hear a negative voice in your head, go back to the basic principles of your training, and get into the right mode.

You freely express vulnerability in your book. Is having a high level of self-awareness helpful in overcoming fear or anxiety during surgery?

Dr. McLaughlin: Many people fear facing the truth, and the truth is that when you are vulnerable, it actually makes you stronger. After publishing Cognitive Dominance, I’ve had so many people say that they will never look at me the same since reading the book. One person said, “it has made me see a totally different side of not just you but of surgeons.”

We always think of surgeons as stoic, and sometimes indifferent to patients. I think any good surgeon cares a lot about their patients. Sometimes, they may not know how to express their feelings and may act in an inappropriate way, such as being aloof or defensive. Also, surgeons may not have the right coping skills to deal with the fear and anxiety that goes along with their job.

With reflection and an open mind, surgeons can learn to better identify and share their feelings. We hold ourselves to an impossible standard that can be destructive in some cases. If you realize that you have to forgive yourself, you can free yourself and grow.

You discuss how fear can cause a toll on surgeons, both physically and mentally. How can spine surgeons protect themselves from or overcome mental fatigue and burnout?

Dr. McLaughlin: One of the rules I have is to never worry about a patient alone. When you are thinking about somebody or there is a case that is bugging you, share it with a colleague or a mentor. Have a couple of lifelines to call. I still have a couple friends from my residency on a text thread that we use as an emergency response line.

You write about using music in the OR. How does music help you and what are your musical preferences during surgery?

Dr. McLaughlin: I have a set music script that puts me in a positive mood, and I always start a surgery with the same music set. I listen to a lot of inspirational music, including country music artists such as Luke Combs. His song “Even Though I’m Leaving” always makes me think of my father and Peter Jannetta, MD, one of my mentors.

Once a surgery is going really well, I will ask the staff what they would like to listen to.

How do you orchestrate your surgical team to reduce fear and keep everyone in a positive frame of mind?

Dr. McLaughlin: I think my routine calms everybody. Every time I perform surgery, I follow the 5 Ps:

  1. Pause: Take a moment to quiet your mind
  2. Patient: “This person needs you today.”
  3. Plan: Go over the details of the case in your mind and discuss the surgical plan with the team.
  4. Positive thought: “There is nobody who can do this as well as you can. You are made for this.”
  5. Prayer: I say a silent prayer.

When I enter the OR, I make sure to say hello to everyone by name. I verbalize every step of the surgical plan with the team, and check that all of the instruments are laid out. The surgery goes much smoother if you communicate with your OR team every single step of the way.

Do you have any other advice for surgeons who are just starting out?

Dr. McLaughlin: The goal of my book was to share what I have learned in my 28 years of experience as a neurosurgeon that can enliven and inspire others.

The main thing I learned is that being a neurosurgeon is a constant journey that moves in and out of the flow state. You may have an amazing experience one day, and then get thrown for a loop the next day because something unexpected happens. It is about figuring a way out of it, birthing a new skill set, and then going back into flow. Just because you may be in a dark spot, that is ok. That is part of life and you need to work through it. Knowing where you are on the map can decrease your stress and anxiety level as well as your chances for burnout.

Cognitive dominance is a true north that you aim for. The more you move towards it, the better you will function as a surgeon, business partner, spouse, and parent.

Dr. McLaughlin’s book, Cognitive Dominance: A Brain Surgeon's Quest to Out-Think Fear is available at Amazon.

Updated on: 02/12/20
Continue Reading
Preventing Spine Surgeon Burnout and Suicide
Mark R. McLaughlin, MD
Princeton Brain, Spine & Sports Medicine

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