For orthopaedic surgeons, the challenge of cognitive fatigue is often unavoidable. Popular science magazines often offer performance-optimization tips for cognitive fatigue that range from obvious advice (such as getting more sleep) to dubious claims (such as dipping one’s face in cold milk). These tips are derived haphazardly from various fields and exaggerated for all contexts, from work to personal life. Historically, surgeons have confronted the problem of cognitive fatigue with a combination of stoicism, humor, denial, transference, and deflection. Unfortunately, it is not working. A prospective study of orthopaedic residents found they were fatigued during 48% of their waking hours and showed signs of cognitive impairment 27% of the time; importantly, these fatigue levels are associated with a higher risk of errors.

To combat the impact of fatigue, surgeons can work to improve cognitive ergonomics in the OR. Cognitive ergonomics is the optimization of one’s mental workload and information processing to match their working cognitive capacity.

Cognitive fatigue in the OR
Cognitive fatigue can manifest as reduced cognition, defaults to shortcuts such as bias, slower and less informed decision-making, and impaired memory, all of which can jeopardize performance and patient safety. A study from Gawande et al. found that about one-third of intraoperative errors may be attributable to excessive physical and decision fatigue. Surgeons can sometimes recognize when fatigue sets in (e.g., noticing slower thought processes or a need to recheck steps), but internal pressure to complete a procedure sometimes precludes mitigation. The culture of surgery has historically valued stamina; however, appreciating that cognitive endurance is finite can be the first step in maintaining high-level decision accuracy.

According to Cognitive Load Theory, the intrinsic load of the surgical task (its inherent complexity) combined with extraneous load from suboptimal environmental optimization can approach the limits of a surgeon’s mental capacity. If cognitive load exceeds what working memory can manage, performance suffers.

The density of decisions a surgeon must make can drive cognitive fatigue. Even small decisions can compromise performance when they disrupt flow, leading to lapses in working memory and executive function, which are limited in capacity. According to Miller et al., working memory can hold only about seven items of information at once. Under high load, errors become more likely. In high “decision density” situations (a term first noted in emergency medicine for rapid-fire decision environments), surgeons may unconsciously degrade the quality of their decisions and rely on cognitive shortcuts. This argument is often used to push for consistent, experienced OR staff who already know the cases, instead of filling schedules with variable personnel.

Surgeons in training face a heavier mental burden. Functional near-infrared spectroscopy shows that novices activate the prefrontal cortex far more than seasoned surgeons because they must deliberately consider each step, even those that experts perform automatically. By contrast, experienced surgeons have turned many routine decisions into automatic processes, which lowers their overall cognitive load and lets them reserve mental capacity for complex judgments that require active reasoning.

Although expertise alleviates some cognitive burden, even veteran surgeons can be overwhelmed by a cascade of intraoperative decisions under stressful conditions. Maintaining situational awareness and clear judgment during high-complexity cases is cognitively expensive but can be mitigated by slowing down momentarily or enlisting input from colleagues. The mental strain of repeated decision-making in surgery is likely to eventually translate to outcome deterioration.

Improving cognitive ergonomics
Surgeons can optimize their cognitive load to “prime the pump” for good decision-making with tactics such as delegating, planning, resting, saying no, and asking for help. Surgeons can implement cognitive aids such as checklists and standard operating procedures for common decision points to conserve cognitive resources for the truly critical, novel decisions. Freeing up working memory can enable creative problem-solving when a surgeon experiences difficulty in the OR.

Intraoperative factors that contribute to cognitive fatigue can be as simple as case duration and difficulty, decision density, sensory overload, and problem-solving strain. However, evidence-based strategies before, during, and after surgery can mitigate fatigue and bolster cognitive resilience. Insights from cognitive psychology, neuroscience, and medical education can be drawn upon and combined to preserve performance, sustain surgical skills over a career, and maintain decision accuracy even under extreme stress.

For example, longer days in the OR can directly correlate with surgeon fatigue and diminished cognitive function. Optimizing cognitive performance in surgery can begin with scheduling and planning case-volume effectively. Fatigue accrues over time, as continuous concentration is required for operative tasks. Orthopaedic operations often span several hours, especially in complex cases, which can lead to lapses in vigilance and slower reaction times as the day goes on. Limiting continuous operating time or ensuring adequate breaks may require building gaps into the schedule.

Building in space and time for recovery between cases is a simple and useful tool. From a neuropsychological perspective, prolonged intense focus may deplete neurotransmitters in the prefrontal cortex involved in attention and decision-making, compounding the subjective sense of mental exhaustion. These can be restored, in part, with rest between cases.

In cognitive psychology, mental imagery of motor tasks has been shown to activate similar neural pathways as actual practice, facilitating skill acquisition and preparedness by relegating some tasks to automatic cognitive processing. Mental rehearsal is a form of cognitive simulation that can reinforce the steps of a procedure and anticipate decision points for quick pivots intraoperatively. Mentally “walking through” a surgery reduces the intrinsic cognitive load during the real operation because the sequence of actions is more familiar.

Surgeons can further optimize cognition by avoiding multitasking, planning cases, optimizing preference cards, and creating systems and workflows that automate routine decisions. Making decisions in advance, rather than relying on a limited working cognitive load in a stressful environment, can also be helpful.

Surgeons need to manage the unchangeable reality of consistently high cognitive loads by optimizing cognitive ergonomics. Decisions surrounding cognitive ergonomics are personal and may potentially pose an administrative challenge to those unfamiliar with these nuances.

Ultimately, surgeons need to be granted autonomy to optimize their environment, schedule their workload, and choose how they manage their cognitive load to leverage cognitive ergonomics in a way that improves patient outcomes.

David M. Bennett, MD, is a pediatric orthopaedic spine surgeon and attending physician at Phoenix Children’s Hospital, focusing on complex spinal deformity, pediatric fracture care, and advanced operative planning.

Pooya Hosseinzadeh, MD, FAAOS, is an associate professor in the Department of Orthopaedic Surgery at Washington University School of Medicine, as well as a member of the AAOS Now Editorial Board.

Keith D. Baldwin, MD, MS, MPH, is an attending pediatric orthopaedic surgeon and director of orthopaedic trauma at the Children’s Hospital of Philadelphia and associate professor of orthopaedic surgery at the Perelman School of Medicine.

Strategies to manage cognitive load in surgery

Surgeons can use several tools and steps to help manage the cognitive load associated with orthopaedic surgery:

1. Mental rehearsal: Mentally simulate complex procedures beforehand to automate steps and anticipate decision points.
2. Checklists and standard operating procedures: Standardize routine tasks to conserve executive bandwidth for critical intraoperative decisions.
3. Strategic delegation: Delegate low-yield or nonessential decisions (e.g., instrument handoff, positioning) to preserve working memory.
4. Cognitive warm-up: Engage in brief preoperative tasks (e.g., knot-tying, simulation) to activate task-specific executive circuits.
5. Micro-breaks: Schedule short, intentional intraoperative breaks to reset attention and relieve musculoskeletal strain.
6. Fatigue-aware scheduling: Avoid long, high-stakes cases after overnight call or late in circadian nadirs (e.g., early morning).
7. Noise and interruption control: Minimize ambient chatter, alarms, and nonessential queries during high-focus segments.
8. Environmental ergonomics: Optimize table height, monitor visibility, and lead burden to reduce postural fatigue.
9. Case-planning discipline: Sequence cases to allow recovery intervals; avoid back-to-back marathons when avoidable.
10. Task-automation systems: Build workflows that eliminate redundant or low-level decisions (e.g., preference card refinement).
11. Recovery buffering: Use quiet call rooms, naps, or silent office time to restore mental resources between cases.
12. Cognitive self-monitoring: Recognize early fatigue cues (e.g., slowed thought, indecision, rechecking) and intervene proactively.
13. Simulation-based stress training: Incorporate decision-making under duress into training to build mental endurance.
14. Visual cleanliness: Declutter the OR visual field to reduce attentional diffusion from unnecessary sensory input.
15. Mindful postoperative recovery: Protect post-operative time with space, autonomy, and control over rest and follow-up timing.

References

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