Measurement of Mental Workload in Clinical Medicine: A Review Study
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paper_title: Navigating towards improved surgical safety using aviation-based strategies.

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Safety practices in the aviation industry are being increasingly adapted to healthcare in an effort to reduce medical errors and patient harm. However, caution should be applied in embracing these practices because of limited experience in surgical disciplines, lack of rigorous research linking these practices to outcome, and fundamental differences between the two industries. Surgeons should have an in-depth understanding of the principles and data supporting aviation-based safety strategies before routinely adopting them. This paper serves as a review of strategies adapted to improve surgical safety, including the following: implementation of crew resource management in training operative teams; incorporation of simulation in training of technical and nontechnical skills; and analysis of contributory factors to errors using surveys, behavioral marker systems, human factors analysis, and incident reporting. Avenues and challenges for future research are also discussed.
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paper_title: Multiple Resources and Mental Workload

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Objective: The objective is to lay out the rationale for multiple resource theory and the particular 4-D multiple resource model, as well as to show how the model is useful both as a design tool and as a means of predicting multitask workload overload. Background: I describe the discoveries and developments regarding multiple resource theory that have emerged over the past 50 years that contribute to performance and workload prediction. Method: The article presents a history of the multiple resource concept, a computational version of the multiple resource model applied to multitask driving simulation data, and the relation of multiple resources to workload. Results: Research revealed the importance of the four dimensions in accounting for task interference and the association of resources with brain structure. Multiple resource models yielded high correlations between model predictions and data. Lower correlations also identified the existence of additional resources. Conclusion: The model was shown to b...
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paper_title: Measuring physician mental workload: reliability and validity assessment of a brief instrument.

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This study examined the reliability and validity of a brief six-item instrument to measure the mental workload experienced by residents for specific patient visits to an ambulatory care clinic. Participating in the study were twenty-two residents in postgraduate years 1 through 3 who were working in the general outpatient clinic of an inner city, private, nonprofit community hospital. Cronbach's alpha coefficient for the instrument was 0.80. Findings supported several theory-based hypotheses on determinants and performance consequences of mental workload. Mental workload was positively correlated with fatigue (r = 0.42, P = 0.03) and inversely correlated with residents' self-rated experience with patients' problems (r = -0.65, P less than 0.001). Residents' performance was measured through self-ratings and faculty physicians' ratings. Mental workload was inversely correlated with self-rated performance (r = -0.67, P less than 0.001). The correlation of mental workload with faculty physician ratings that reflected the technical dimension of patient care (physician examination, medications, and procedures) was r = -0.38 (P = 0.04). With mental workload squared, the correlation was r = -0.45 (P = 0.02) and the form of the relationship, consistent with the hypothesis, was a slightly downward sloping curve. Limitations of this research are discussed as well as suggestions for further research.
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paper_title: Monitor surveillance and vigilance of anesthesia residents.

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BACKGROUND ::: Anesthesia residents take longer to detect changes in electronically monitored data during the induction phase of anesthesia during the maintenance phase. This study was performed to investigate the reasons for this delay and to validate a method of measuring vigilance. ::: ::: ::: METHODS ::: The activity of ten residents was studied during 73 surgical procedures. Data were collected during three 15-min periods from each case: induction, starting with application of the electrocardiograph; maintenance, an arbitrary period between induction and emergence; and emergence, ending with detachment of the electrocardiograph. Vigilance was measured as the time taken to detect a change, from normal to abnormal, of an artificial parameter displayed on the physiologic monitor (response time). An observer simultaneously recorded each time that the resident looked toward the monitors. ::: ::: ::: RESULTS ::: Vigilance to the monitor display was less during induction and emergence than during maintenance (P < 0.005). Residents spent less total time watching monitors during induction than during maintenance (P < 0.005), and the duration of each monitor observation was shorter (P < 0.0005). Anesthesia residents usually looked at the monitors several times before detecting the abnormal value. The measure of anesthesia vigilance correlated with independent measures of monitor watching time and frequency. ::: ::: ::: CONCLUSIONS ::: The results suggest that during induction of anesthesia, which is a period of high anesthesiologist workload, residents glance toward monitors to gather data rather than scan displays. The results help to validate the method for measuring anesthesia vigilance.
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paper_title: The effect of electronic record keeping and transesophageal echocardiography on task distribution, workload, and vigilance during cardiac anesthesia.

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BACKGROUND ::: Electronic anesthesia record keeping (EARK) systems increasingly are used in the operating room, but studies have only recently begun to investigate their effect on anesthesia task performance. Teak analysis, workload assessment, and vigilance assessment techniques were used to study senior residents providing anesthesia for coronary artery bypass graft (CABG) procedures. The impact on anesthesia residents' workload of the routine use of transesophageal echocardiography (TEE) also was examined. ::: ::: ::: METHODS ::: Before each case, the record keeping system was randomly selected as either electronic (Distek ARKIVE; EARK) or traditional manual recording (MAN). Twenty CABG procedures (10 EARK and 10 MAN) were examined, with observation commencing with anesthetic induction and terminating on initiation of cardiopulmonary bypass. The activities of each resident, divided into 32 task categories (e.g., "laryngoscopy," "observe monitors," etc.), were recorded by a trained observer using a computer. The response latency to a randomly activated alarm light was used as a measure of vigilance ("vigilance latency"). Workload was rated by subject and observer at random 10- to 15-min intervals throughout the case. Data analysis included calculation of workload density (number of tasks/min multiplied by task-specific workload values) and task-links (relationship between sequential tasks). ::: ::: ::: RESULTS ::: The two groups had a similar distribution of tasks before intubation. In only 4 of the 20 cases studied did any manual record keeping occur before intubation. After intubation, the EARK group spent less time record keeping and using the TEE but more time observing the monitors and conversing with the attending physician than the MAN group did. All subjects reported significantly higher workload scores before intubation compared with after intubation. Similarly, vigilance latency was greater before intubation compared with after intubation (57 vs. 31 s; P < 0.001). There were no significant differences between the two record keeping groups in subjective workload scores, workload density, or vigilance latency. During TEE use, vigilance latency was significantly longer, and workload density was greater than during other monitoring or recording tasks. ::: ::: ::: CONCLUSIONS ::: This study provides an objective description of the task distribution and workload during the administration of anesthesia for cardiac surgery. Under the conditions of this study. EARK use modestly decreased the time spent record keeping during the postintubation prebypass period. However, there was no effect of EARK either on vigilance or several measures of workload. TEE use was associated with increased workload and possibly decreased vigilance.
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paper_title: Construct and face validity and task workload for laparoscopic camera navigation: virtual reality versus videotrainer systems at the SAGES Learning Center

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Background: Laparoscopic camera navigation (LCN) training on simulators has demonstrated transferability to actual operations, but no comparative data exist. The objective of this study was to compare the construct and face validity, as well as workload, of two previously validated virtual reality (VR) and videotrainer (VT) systems. Methods: Attendees (n = 90) of the SAGES 2005 Learning Center performed two repetitions on both VR (EndoTower! ) and VT (Tulane Trainer) LCN systems using 30" laparoscopes and completed a questionnaire regarding demographics, simulator characteristics, and task workload. Construct validity was determined by comparing the performance scores of subjects with various levels of experience according to five parameters and face validity according to eight. The validated NASA-TLX questionnaire that rates the mental, physical, and temporal demand of a task as well as the performance, e!ort, and frustration of the subject was used for workload measurement. Results: Construct validity was demonstrated for both simulators according to the number of basic laparoscopic cases (p = 0.005), number of advanced cases (p < 0.001), and frequency of angled scope use (p < 0.001), and only for VT according to training level (p < 0.001) and fellowship training (p = 0.008). Face validity ratings on a 1-20 scale averaged 15.4 ± 3 for VR vs. 16 ± 2.6 for VT (p = 0.04). Ninety-six percent of participants rated both simulators as valid educational tools. The NASA-TLX overall workload score was 69.5 ± 24 for VR vs. 68.8 ± 20.5 for VT (p = 0.31). Conclusions: This is the largest study to date that compares two validated LCN simulators. While subtle differences exist, both VR and VT simulators demonstrated excellent construct validity, good face validity, and acceptable workload parameters. These systems thus represent useful training devices and should be widely used to improve surgical performance.
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paper_title: Positive effects of electronic patient records on three clinical activities

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Abstract Purpose To investigate the effects of a fully functional electronic patient record (EPR) system on clinicians’ work during team conferences, ward rounds, and nursing handovers. Method In collaboration with clinicians an EPR system was configured for a stroke unit and in trial use for 5 days, 24 h a day. During the trial period the EPR system was used by all clinicians at the stroke unit and it replaced all paper records. The EPR system simulated a fully integrated clinical-process EPR where the clinicians experienced the system as if all transactions were IT supported. Such systems are not to be expected to be in operational use in Denmark until at least 2 years from now. The EPR system was evaluated with respect to its effects on clinicians’ mental workload, overview, and need for exchanging information. Effects were measured by comparing the use of electronic records with the use of paper records prior to the trial period. The data comprise measurements from 11 team conferences, 7 ward rounds, and 10 nursing handovers. Results During team conferences the clinicians experienced a reduction on five of six subscales of mental workload, and the physicians experienced an overall reduction in mental workload. The physician in charge also experienced increased clarity about the importance of and responsibilities for work tasks, and reduced mental workload during ward rounds. During nursing handovers the nurses experienced fewer missing pieces of information and fewer messages to pass on after the handover. Further, the status of the nursing plans for each patient was clearer for all nurses at the nursing handovers except the nurse team leader, who experienced less clarity about the status of the plans. Conclusion The clinicians experienced positive effects of electronic records over paper records for the three clinical activities involved in the evaluation. This is important in its own right and likely to affect clinicians’ acceptance of EPR systems, their command of their work, and consequently the attainment of ‘downstream’ effects on patient outcomes.
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paper_title: Comparison of four different display designs of a novel anaesthetic monitoring system, the ‘integrated monitor of anaesthesia (IMA™)’

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BACKGROUND ::: A novel monitoring system (integrated monitor of anaesthesia, IMA) which integrates three components of general anaesthesia on one single display was developed. The focus of this study was to evaluate the performance and user-friendliness of four different display designs. ::: ::: ::: METHODS ::: Four interface displays of the IMA were developed, including one numerical, one numerical and graphical (mixed numerical-graphical), one only graphical, and one an advanced two-dimensional graphical display. Each of the four displays was evaluated in a random order by 10 staff anaesthetists and 10 residents/fellows using a set of five scenarios. Scenarios involved one or more abnormal variables that participants had to verbally phrase. For each interface test, reaction time, response accuracy, and NASA-Task Load Index were measured and compared. ::: ::: ::: RESULTS ::: The numerical, graphical, and advanced-graphical interfaces yielded similar median reaction times, respectively, 7.99 s (5.15-10.79), 8.21 s (6.20-11.88), and 9.43 s (6.19-13.3). Reaction times were significantly shorter (P<0.006) with the mixed numerical-graphical interface: 6.26 s (4.52-8.32). The correct response rate was significantly lower in the graphical interface. The three others presented no statistical difference when compared among each other. The mixed numerical-graphical interface yielded a significantly lower NASA-TLX than the numerical and the advanced-graphical interfaces (19/100 vs 34/100, P<0.003). ::: ::: ::: CONCLUSIONS ::: A mixed numerical-graphical display design appears to present the best results in terms of user reaction times, response accuracy, and performance index when detecting abnormal critical events.
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paper_title: Should previous mammograms be digitised in the transition to digital mammography?

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Breast screening specificity is improved if previous mammograms are available, which presents a challenge when converting to digital mammography. Two display options were investigated: mounting previous film mammograms on a multiviewer adjacent to the workstation, or digitising them for soft copy display. Eight qualified screen readers were videotaped undertaking routine screen reading for two 45-min sessions in each scenario. Analysis of gross eye and head movements showed that when digitised, previous mammograms were examined a greater number of times per case (p = 0.03), due to a combination of being used in 19% more cases (p = 0.04) and where used, looked at a greater number of times (28% increase, p = 0.04). Digitising previous mammograms reduced both the average time taken per case by 18% (p = 0.04) and the participants' perceptions of workload (p < 0.05). Digitising previous analogue mammograms may be advantageous, in particular in increasing their level of use.
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paper_title: Measuring the workload of the anesthesiologist.

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Workload is an important determinant of human performance during complex dynamic tasks. We indirectly measured the mental workload of nine anesthesia residents during 19 cases using a secondary (subsidiary) task paradigm in which performance on an extra task (problems in mathematical addition occurring approximately every 45 s) was used as a probe of a subject's "spare capacity." Excess response time (above baseline) correlated with activities like "manual task" and "speaking with the attending anesthesiologist." The addition problem was either skipped or had a high excess response time (greater than 30 s) in 40% of presentations. The complexity of a case and the experience level of the resident interacted in determining the workload. Subjective workload ratings confirmed that induction of and emergence from anesthesia were periods of highest workload, with "attention" as the dominant cognitive requirement. The anesthesiologist's spare capacity may often be limited during anesthesia. These types of workload measurement techniques should be applied in controlled studies to better define the factors that increase workload.
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paper_title: Speech recognition for the anaesthesia record during crisis scenarios

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Abstract Introduction This article describes the evaluation of a prototype speech-input interface to an anaesthesia patient record, conducted in a full-scale anaesthesia simulator involving six doctor–nurse anaesthetist teams. Objective The aims of the experiment were, first, to assess the potential advantages and disadvantages of a vocal interface compared to the traditional touch-screen and keyboard interface to an electronic anaesthesia record during crisis situations; second, to assess the usability in a realistic work environment of some speech input strategies (hands-free vocal interface activated by a keyword; combination of command and free text modes); finally, to quantify some of the gains that could be provided by the speech input modality. Methods Six anaesthesia teams composed of one doctor and one nurse were each confronted with two crisis scenarios in a full-scale anaesthesia simulator. Each team would fill in the anaesthesia record, in one session using only the traditional touch-screen and keyboard interface while in the other session they could also use the speech input interface. Audio-video recordings of the sessions were subsequently analysed and additional subjective data were gathered from a questionnaire. Analysis of data was made by a method inspired by queuing theory in order to compare the delays associated to the two interfaces and to quantify the workload inherent to the memorisation of items to be entered into the anaesthesia record. Results The experiment showed on the one hand that the traditional touch-screen and keyboard interface imposes a steadily increasing mental workload in terms of items to keep in memory until there is time to update the anaesthesia record, and on the other hand that the speech input interface will allow anaesthetists to enter medications and observations almost simultaneously when they are given or made. The tested speech input strategies were successful, even with the ambient noise. Speaking to the system while working appeared feasible, although improvements in speech recognition rates are needed. Conclusion A vocal interface leads to shorter time between the events to be registered and the actual registration in the electronic anaesthesia record; therefore, this type of interface would likely lead to greater accuracy of items recorded and a reduction of mental workload associated with memorisation of events to be registered, especially during time constrained situations. At the same time, current speech recognition technology and speech interfaces require user training and user dedication if a speech interface is to be used successfully.
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paper_title: Measuring mental workload during the performance of advanced laparoscopic tasks

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INTRODUCTION ::: Mental workload is a finite resource and is increased while learning new tasks and performing complex tasks. Measurement of a surgeon's mental workload may therefore be an indication of expertise. We hypothesized that surgeons who were expert at laparoscopic suturing would have more spare mental resources to perform a secondary task, compared with surgeons who had just started to learn suturing. ::: ::: ::: METHODS ::: Standardized suturing tasks were performed on a bench-top model. Twelve junior residents (novices) and nine fellows and attending surgeons (experts) were instructed to perform as many sutures as possible in 6 min. An adjacent monitor was placed 15 degrees off axis to the first and randomly displayed 30 true visual signals among 90 false ones. Participants were required to identify the true signals while continuing to suture. Laparoscopic sutures were evaluated using the Fundamentals of Laparoscopic Surgery (FLS) scoring system. The secondary (visual detection) task was evaluated by calculating the rate of missed true signals or detection of false signals. ::: ::: ::: RESULTS ::: Experts completed significantly more secure sutures (6 +/- 2) than novices (3 +/- 1; p = 0.001). The suture performance score was 50 +/- 20 for experts, significantly higher than for novices (29 +/- 10; p = 0.005). The rate for detecting visual signals was higher for experts (98%) compared with for novices (93%; p = 0.041). ::: ::: ::: CONCLUSION ::: Practice develops automaticity, which reduces the mental workload and allows surgeons to have sufficient spare mental resources to attend to a secondary task. Visual detection provides a simple and reliable way to assess mental workload and situation awareness abilities of surgeons during skills training, and may be an indirect measure of expertise.
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paper_title: A simulation-based evaluation of a graphic cardiovascular display.

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INTRODUCTION ::: A graphic presentation of complex information can facilitate early detection and management of adverse events. Prior work found that graphical presentation of selected cardiovascular variables led to earlier detection of a simulated ischemic event. Based on these findings, a second evaluation explored the utility of a graphical cardiovascular display (GCD) in a variety of simulated adverse cardiopulmonary events for two different display configurations. In this evaluation, we revised the GCD to present hemodynamic variables with or without a pulmonary artery catheter. Our hypotheses were that the revised GCD would improve detection of adverse cardiopulmonary events and add no additional perceived workload. ::: ::: ::: METHODS ::: Sixteen anesthesiologists and anesthesia residents were enrolled in a simulation-based evaluation of the GCD. Participants were randomly split into two groups balanced for expertise and asked to manage six simulated adverse cardiopulmonary events. The GCD was present in half of the simulations, balanced across scenarios and groups. Participants' verbalizations and actions during each scenario were recorded and transcribed. Transcripts of treatment interventions were subsequently rated by two blinded expert anesthesiologists. Perceived workload, time to detection, and proper treatment of the adverse event were compared between groups. ::: ::: ::: RESULTS ::: Experts ranked anesthesiologists using the GCD as being more effective overall and individually in three of six scenarios. Use of the GCD was demonstrated to influence the time to detection and the time to treatment of some critical events. There were no workload differences between display groups. ::: ::: ::: DISCUSSION ::: Treatment intervention by participants using the GCD was rated superior by two blinded experts. The presence of the GCD resulted in a modest improvement in the time to detect myocardial ischemia and increased pulmonary capillary wedge pressure. The GCD may be a useful adjunct to monitor patients during adverse cardiopulmonary events.
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paper_title: A Measure of Physician Mental Work Load in Internal Medicine Ambulatory Care Clinics

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Physician mental work load is an important variable intervening between work demands imposed on physicians and physician performance. A brief instrument was developed to measure the mental work load experienced during a clinic session in internal medicine ambulatory care hospital clinics. The instru
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paper_title: An Objective Methodology for Task Analysis and Workload Assessment in Anesthesia Providers

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BackgroundAdministering anesthesia is a complex task in which either human or equipment failure can have disastrous consequences. An improved understanding of the nature of the anesthesiologist's job could provide a more rational basis for improvements in provider training as well as the design of a
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paper_title: Clinical information displays to improve ICU outcomes

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PURPOSE ::: In a previous study, we compared a prototype ecological display (ED) that represented physiological data in a structured pictorial format with two bar graph displays [J.A. Effken, Improving clinical decision making through ecological interfaces, Ecol. Psych. 18 (2006) 283-318]. In ED and the first bar graph display, data were grouped hierarchically based on a cognitive work analysis (CWA); in the second bar graph display they were grouped as usually collected. Treatment efficiency (i.e., percentage of time seven variables in the CWA model were in target range) improved similarly with the two displays incorporating the CWA order for intensive care unit (ICU) residents, but not for novice ICU nurses. Hypothesized reasons for this result included: insufficient practice with novel displays; use of identical histories across displays; insufficient clinical knowledge; and the variables used in the efficiency analysis, which included only one of ED's four integrated design elements. In the current study we tested these hypotheses. ::: ::: ::: METHODS ::: We asked ICU nurses assigned to three knowledge groups based on intensive care and hemodynamic monitoring pretests to identify and treat oxygenation problems presented via ED and the first bar graph display (BGD) in an experimental laboratory simulation. We measured the impact of display, clinical scenario, data level, knowledge, presentation order, and practice extent on event recognition, treatment efficiency, cognitive workload, and user satisfaction. ::: ::: ::: RESULTS ::: The two displays produced little difference in recognition speed or overall cognitive workload, but user satisfaction was greater with ED. When 12 variables were included in the analysis, treatment efficiency improved with ED; when only 7 were measured, BGD prevailed. The results suggest benefits for the kind of synthesis provided in ED, but also a potential limitation. If too many different pictorial formats are used in a display, detecting critical events may be more difficult.
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paper_title: The influence of workload on the mental state of the primary health care physician.

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The work factors involved in physicians' mental workload were analysed. The study settings were 116 physicians (general practitioners, paediatricians and residents in family programmes working in out-patient clinics) (Primary Health Care Centres) in Spain. The questionnaire used measured the mental workload and the work activity over a period of 5 days. The mental workload covered seven dimensions: mental effort, physical effort, difficulty, priority, modify standards of visit, overlap, and stress. Its Cronbach's alpha coefficient was 0.80. The mental workload correlated positively with all variables measuring the workload activity. However, when the multiple regression analysis (stepwise met) was assessed, only the number of room visits, the referrals by nurse to physician, the room emergencies, the level of administrative tasks, the patients with complex pathologies, and the workload adequacy remained significant. The physicians' years of experience did not correlate with mental workload. The influence of diverse work activities in each of the mental workload dimensions was investigated. We conclude that the number of patient visits and organizational factors determine physicians' mental workload.
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paper_title: Performing laparoscopic surgery is significantly more stressful for the surgeon than open surgery

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BACKGROUND ::: The awkward visual and physical interface of video-endoscopic surgery (VES) has been shown to increase the physical workload of the surgeon, yet there is a lack of objective information on the mental effort and stress demanded by VES techniques. This study addresses the hypothesis that VES is more stressful than open surgery using an ergonomic analysis of surgical tasks in a laboratory setting. ::: ::: ::: METHODS ::: A portable ergonomic work station was developed using a software Virtual Instrument (VI) interfaced with electronic hardware to compare the mental workload of 28 surgeons. The task was knot tying. The independent variable was work condition: rest, open technique, or VES technique. Dependent variables were tonic skin conductance level (SCL), electrooculogram (EOG), and subjective reports of concentration (CON) and stress (STR). Statistical analysis used nonparametric methods. ::: ::: ::: RESULTS ::: Subjects tied fewer knots using the VES technique (p < 0.05). The SCL increased progressively from rest to the open task to the VES task (p < 0.05), correlating with the subjects' reported increase in mental stress level (p < 0.05). Eye blinks decreased from rest to the open task (p < 0.05), consistent with the subjects' reported increase in level of mental concentration. From the open to the VES task, eye blinks increased (p < 0.05), as would be expected given the greater demands of the VES task. Experienced subjects demonstrated less variability in SCL levels across tasks. ::: ::: ::: CONCLUSIONS ::: VES technique requires greater concentration and places greater mental stress on surgeons than to open surgery. More experience with VES may decrease this effect. Studies are needed to improve the human-technology interface the stress.
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paper_title: Multiple measures of anesthesia workload during teaching and nonteaching cases.

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UNLABELLED ::: In this study, we sought to examine several measures of anesthesia provider workload during different phases of anesthesia care and during teaching and nonteaching cases. Clinical work was assessed in real-time during 24 general anesthetics performed by consenting anesthesia providers. Workload was measured using physiological (provider heart rate), psychological (self-assessment and observer rating), and procedural (response latency to an alarm light and workload density) techniques. Clinicians' heart rates, observer and self-reported workload scores, and nonteaching workload density were consistently increased during anesthetic induction and emergence compared with maintenance. In nonteaching cases, workload density correlated with heart rate and with psychological workload. Workload density during teaching cases did not decrease during the induction and was significantly greater than during nonteaching cases. Alarm-light response latency (a measure of clinical vigilance) was significantly prolonged during the teaching compared with nonteaching cases. These results suggest that intraoperative teaching increases the workload of the clinician instructor and may reduce vigilance during anesthesia care. Additionally, multiple workload measures may provide a more comprehensive profile of the work demands of clinical cases. ::: ::: ::: IMPLICATIONS ::: Psychological, physiological, and procedural workload measures during routine general anesthesia cases documented the increased work demands of induction and emergence. Intraoperative teaching increased workload and decreased vigilance, suggesting the need for caution when educating during patient care.
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paper_title: Quantitative description of the workload associated with airway management procedures

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Abstract Study Objectives: To measure the workload associated with specific airway management tasks. Setting and Intervention: Written survey instrument. Patients: 166 Stanford University and 75 University of California, San Diego, anesthesia providers. Measurements and Main Results: Subjects were asked to use a seven-point Likert-type scale to rate the level of perceived workload associated with different airway management tasks with respect to the physical effort, mental effort, and psychological stress they require to perform in the typical clinical setting. The 126 subjects completing questionnaires (overall 52% response rate) consisted of 43% faculty, 26% residents, 23% community practitioners, and 8% certified registered nurse-anesthetists (CRNAs). Faculty physicians generally scored lower workload measures than residents, whereas community practitioners had the highest workload scores. Overall, workload ratings were lowest for laryngeal mask airway (LMA) insertion and highest for awake fiberoptic intubation. Airway procedures performed on sleeping patients received lower workload ratings than comparable procedures performed on awake patients. Direct visualization procedures received lower workload ratings than fiberoptically guided procedures. Conclusions: These kinds of data may permit more objective consideration of the nonmonetary costs of technical anesthesia procedures. The potential clinical benefits of the use of more complex airway management techniques may be partially offset by the impact of increased workload on other clinical demands.
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paper_title: Development and evaluation of a graphical anesthesia drug display.

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BACKGROUND ::: Usable real-time displays of intravenous anesthetic concentrations and effects could significantly enhance intraoperative clinical decision-making. Pharmacokinetic models are available to estimate past, present, and future drug effect-site concentrations, and pharmacodynamic models are available to predict the drug's associated physiologic effects. ::: ::: ::: METHODS ::: An interdisciplinary research team (bioengineering, architecture, anesthesiology, computer engineering, and cognitive psychology) developed a graphic display that presents the real-time effect-site concentrations, normalized to the drugs' EC(95), of intravenous drugs. Graphical metaphors were created to show the drugs' pharmacodynamics. To evaluate the effect of the display on the management of total intravenous anesthesia, 15 anesthesiologists participated in a computer-based simulation study. The participants cared for patients during two experimental conditions: with and without the drug display. ::: ::: ::: RESULTS ::: With the drug display, clinicians administered more bolus doses of remifentanil during anesthesia maintenance. There was a significantly lower variation in the predicted effect-site concentrations for remifentanil and propofol, and effect-site concentrations were maintained closer to the drugs' EC(95). There was no significant difference in the simulated patient heart rate and blood pressure with respect to experimental condition. The perceived performance for the participants was increased with the drug display, whereas mental demand, effort, and frustration level were reduced. In a post-simulation questionnaire, participants rated the display to be a useful addition to anesthesia monitoring. ::: ::: ::: CONCLUSIONS ::: The drug display altered simulated clinical practice. These results, which will inform the next iteration of designs and evaluations, suggest promise for this approach to drug data visualization.
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paper_title: Do novices display automaticity during simulator training

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Abstract Background The objective of this study was to investigate whether novices improve their ability to develop multitask (ie, automaticity) with accumulating experience on a simulated laparoscopic task. Methods In this prospective study, novices (12 premed students) trained for 4 months in laparoscopic suturing. Simultaneously with suturing, participants performed a visual–spatial secondary task to assess their spare attentional capacity. Trainees were required to achieve expert-derived levels in both suturing (520 score) and the secondary task (target 73%). Their performance was assessed with objective scores, and their ability to multitask during training was examined. Results After 10 ± 5 hours and 84 ± 41 repetitions, participants demonstrated improvements in their suturing (70%, P P = 0.08) compared with their baseline scores. During the study period, 11 of 12 participants achieved suturing proficiency, but no one achieved secondary-task proficiency. Longer training times correlated with higher secondary-task scores ( r = .68, P 100 repetitions (n = 4) achieved higher secondary-task scores ( P Comments This study provides evidence for improved automaticity at advanced stages of simulator training. Although novices achieve simulator proficiency after relatively short training durations, the attainment of automaticity requires substantially longer training periods. Further study of this concept is warranted and is currently underway.
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paper_title: Anesthesiologists and acute perioperative stress: a cohort study.

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UNLABELLED ::: Previous studies have indicated that many anesthesiologists exhibit symptoms of chronic stress. There is a paucity of data, however, regarding the existence of acute stress signs among anesthesiologists. Anesthesiologists from three practice settings (n = 38) were studied while they were anesthetizing 203 patients. Heart rate (HR) was recorded continuously and arterial blood pressure (BP) was measured hourly and immediately after each induction. Anxiety levels and salivary cortisol levels were also assessed after each induction. Comparison BP and HR data were obtained from the anesthesiologists during a nonclinical day. We found that anesthesiologists' HR increased during the anesthetic process compared with morning baseline HR (P = 0.008). This HR increase, however, was not clinically significant; the average HR during the anesthetic pro- cess ranged from 80 +/- 12 to 84 +/- 11 bpm. Similarly, although both systolic and diastolic BP after inductions were increased compared with baseline BP (P = 0.001), this increase was not clinically significant. In 9% of the inductions, however, systolic BP exceeded 140 mm Hg, and in 17% of all inductions, diastolic BP exceeded 90 mm Hg. Finally, the average BP of anesthesiologists during a clinical day was not different from the average BP during a nonclinical day (P = 0.9). Self-reported anxiety did not increase significantly after inductions (P = 0.15). An analysis of Holter tapes revealed no rhythm abnormalities and no signs of myocardial ischemia. We conclude that the practice of anesthesiology is associated with minor manifestations of acute physiologic stress during the perioperative process. ::: ::: ::: IMPLICATIONS ::: Anesthesiologists experience minor psychologic stress while involved in the anesthetic process.
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paper_title: Tracking workload in the emergency department.

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OBJECTIVE ::: The primary objective of this study was to create a methodology for measuring transient levels of physician workload in a live emergency department (ED) environment. ::: ::: ::: BACKGROUND ::: Characterizing, defining, and measuring aspects of this interrupt-driven work environment represent the preliminary steps in addressing impending issues concerning ED overcrowding, efficiency, and patient and provider safety. ::: ::: ::: METHODS ::: A time-motion task analysis was conducted. Twenty emergency medicine (EM) physicians were observed for 180-min intervals in an ED of an academic medical center. Near continuous workload measures were developed and used to track changing workload levels in time. These measures were taken from subjective, objective, and physiological perspectives. The NASA-Task Load Index was administered to each physician after observational sessions to measure subjective workload. Physiological measurements were taken throughout the duration of the observation to measure stress response. Additional information concerning physicians' patient quantity and patient complexity was extracted from the ED information system. ::: ::: ::: RESULTS ::: Graphical workload profiles were created by combining observational and subjective data with system state data. Methodologies behind the creation of workload profiles are discussed, the workload profiles are compared, and quantitative and qualitative analyses are conducted. ::: ::: ::: CONCLUSION ::: Using human factors methods to measure workload in a setting such as the ED proves to be challenging but has relevant application in improving the efficiency and safety of EM. ::: ::: ::: APPLICATION ::: Techniques implemented in this research are applicable in managing ED staff and real-time monitoring of physician workload.
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paper_title: Emergency physicians ’ behaviors and workload in the presence of an electronic whiteboard

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BACKGROUND ::: As the demands on the emergency medicine (EM) system continue to increase, improvements in the organization of work and the access to timely clinical and system information will be required for providers to manage their workload in a safe and efficient manner. Information technology (IT) solutions are beginning to find their place in the emergency department (ED) and it is time to begin understanding how these systems are effecting physician behavior, communication and workload. ::: ::: ::: METHODS ::: The study used a time-in-motion, primary task analyses to study faculty and resident physician behavior in the presence of an electronic whiteboard. The NASA-Task Load Index (TLX) was used to measure subjective workload and the underlying dimensions of workload at the end of each physician observation. Work, communication and workload were characterized using descriptive statistics and compared using Mann-Whitney U-tests. ::: ::: ::: RESULTS ::: Physicians in our study performed more tasks and were interrupted less than physicians studied previously in conventional EDs. Interruptions interrupted direct patient care tasks less than other clinical activities. Temporary interruptions appear to be a major source of inefficiency in the ED, and likely a major threat to patient safety. Face-to-face interruptions persist even in the presence of advanced IT systems, such as the electronic whiteboard. Faculty physicians exhibited lower workload scores than resident physicians. Frustration was a significant contributing factor to workload in resident physicians. All physicians ranked temporal demands and mental demands as major contributing factors to workload. ::: ::: ::: CONCLUSION ::: The results indicate that the electronic whiteboard improves the efficiency of work and communication in the ED. IT solutions may have great utility in improving provider situational awareness and distributing workload among ED providers. The results also demonstrate that IT solutions alone will not solve all problems in the ED. IT solutions will probably be most effective in improving efficiency and safety outcomes when paired with human-based interventions, such as crew resource management. Future studies must investigate team interaction, workload and situational awareness, and the association of these factors to patient and provider outcomes.
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paper_title: Drug Delivery as Control Task: Improving Performance in a Common Anesthetic Task

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Objective: To conceptualize delivery of anesthesia as a control task, similar to control tasks in nonmedical domains, and to evaluate how presentation of new information and feedback affects task performance. Background: In anesthesia, integrated monitors that show intravenous drug and effect-site concentrations in a patient currently do not exist. However, using real-time displays of intravenous anesthetic concentrations and effects could significantly enhance intraoperative clinical performance. Pharmacological models are available to estimate past, present, and future drug concentrations in the brain and to predict the drug's physiological effects. A display that integrates pharmacological models and visualizes drug concentrations was developed and tested to see if this drug display significantly improved clinical performance. Method: Thirty three anesthesiologists with different levels of expertise administered anesthesia to simulated patients in a high-fidelity patient simulator. The experimental gro...
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paper_title: Applying Human Factors to the Design of Medical Equipment: Patient-Controlled Analgesia

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Objective. Medical instruments commonly have poorly designed user interfaces that promote human errors with life-threatening consequences. The primary hypothesis of this study was that a specific user interface could be made safer and more efficient if redesigned using human factors techniques and principles. Methods. The user interface of a commercially available patient-controlled analgesia (PCA) pump, the Abbott Lifecare 4100 PCA Plus II infuser, was evaluated using a cognitive task analysis of bench tests and field observations. Based on this analysis, the user interface was redesigned. Important elements of the new design include a dialog structure with fewer steps, a dialog overview showing the user's location in the programming sequence, better command feedback, easier error recovery, and clearer labels and messages. The changes were evaluated by comparing a computer prototype of the new interface with a computer simulation of the old one. Twelve student nurses performed six programming tasks with each interface. Task completion time, number of errors, and subjective mental workload were collected for each trial. Results. The results showed significantly faster programming times (F(1,11) = 6.85, P < 0.025), lower mental workload ratings (χ2(1) = 4.45, p < 0.025, one-tailed), and fewer errors (χ2(1) = 3.33, p < 0.05, one-tailed) with the new interface. Conclusion. Adopting a human factors approach to redesigning the PCA interface led to significantly faster, easier, and more reliable performance. These findings have important implications for improving the design of other computer-based medical equipment.
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paper_title: How much feedback is necessary for learning to suture?

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Background ::: Many laparoscopic simulation training systems exist and have been shown to transfer learning of surgical skills to the operating room. The manner in which the training is structured to maximize learning has not been examined. There are many aspects to the acquisition of laparoscopic skills during training, one of which is the availability of knowledge of results (KR). Knowledge of results is information about the outcome of motor skill execution, usually provided to individuals at the end of the execution. The timing and nature of KR can affect how well people learn new motor skills. In addition, detailed instruction during learning can also affect skill acquisition. We studied the effects of KR and instruction on the learning curve of a suturing and knot-tying task. We hypothesized that KR was necessary for skill acquisition, and that detailed instruction would help trainees to learn to perform the task more correctly and reach a performance plateau earlier. In addition, the overall workload of a trainee during training would decrease as skills improved, especially when KR and coaching were provided.
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paper_title: Redefining simulator proficiency using automaticity theory

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Abstract Background Automaticity is a characteristic of expertise defined by the ability to perform a task without significant demands on attention. Our objective was to assess whether a visual–spatial task that measures spare attentional capacity would distinguish among individuals with different levels of laparoscopic expertise. Methods The performance of novices (n = 10), surgery residents (n = 9), laparoscopy experts (n = 3), and individuals previously trained (n = 7) to proficiency in laparoscopic suturing on simulators but without operative experience (trained individuals) was measured under dual-task conditions. Participants performed laparoscopic suturing for 10 minutes on a video trainer simulator using the Fundamentals of Laparoscopic Surgery suturing model (primary task) while at the same time they responded to a visual–spatial secondary task. Results Experts and trained individuals outperformed both residents and novices on the suturing task ( P P Conclusions A visual–spatial secondary task that assesses spare attentional capacity may help distinguish among individuals of variable laparoscopic expertise when standard performance measures fail to do so. Such automaticity metrics may improve current simulator training and assessment methods and warrants further investigation.
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paper_title: Construct and face validity and task workload for laparoscopic camera navigation: virtual reality versus videotrainer systems at the SAGES Learning Center

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Background: Laparoscopic camera navigation (LCN) training on simulators has demonstrated transferability to actual operations, but no comparative data exist. The objective of this study was to compare the construct and face validity, as well as workload, of two previously validated virtual reality (VR) and videotrainer (VT) systems. Methods: Attendees (n = 90) of the SAGES 2005 Learning Center performed two repetitions on both VR (EndoTower! ) and VT (Tulane Trainer) LCN systems using 30" laparoscopes and completed a questionnaire regarding demographics, simulator characteristics, and task workload. Construct validity was determined by comparing the performance scores of subjects with various levels of experience according to five parameters and face validity according to eight. The validated NASA-TLX questionnaire that rates the mental, physical, and temporal demand of a task as well as the performance, e!ort, and frustration of the subject was used for workload measurement. Results: Construct validity was demonstrated for both simulators according to the number of basic laparoscopic cases (p = 0.005), number of advanced cases (p < 0.001), and frequency of angled scope use (p < 0.001), and only for VT according to training level (p < 0.001) and fellowship training (p = 0.008). Face validity ratings on a 1-20 scale averaged 15.4 ± 3 for VR vs. 16 ± 2.6 for VT (p = 0.04). Ninety-six percent of participants rated both simulators as valid educational tools. The NASA-TLX overall workload score was 69.5 ± 24 for VR vs. 68.8 ± 20.5 for VT (p = 0.31). Conclusions: This is the largest study to date that compares two validated LCN simulators. While subtle differences exist, both VR and VT simulators demonstrated excellent construct validity, good face validity, and acceptable workload parameters. These systems thus represent useful training devices and should be widely used to improve surgical performance.
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paper_title: Measuring the workload of the anesthesiologist.

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Workload is an important determinant of human performance during complex dynamic tasks. We indirectly measured the mental workload of nine anesthesia residents during 19 cases using a secondary (subsidiary) task paradigm in which performance on an extra task (problems in mathematical addition occurring approximately every 45 s) was used as a probe of a subject's "spare capacity." Excess response time (above baseline) correlated with activities like "manual task" and "speaking with the attending anesthesiologist." The addition problem was either skipped or had a high excess response time (greater than 30 s) in 40% of presentations. The complexity of a case and the experience level of the resident interacted in determining the workload. Subjective workload ratings confirmed that induction of and emergence from anesthesia were periods of highest workload, with "attention" as the dominant cognitive requirement. The anesthesiologist's spare capacity may often be limited during anesthesia. These types of workload measurement techniques should be applied in controlled studies to better define the factors that increase workload.
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paper_title: Assessing Mental Workload During Laparoscopic Surgery

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Although the use of performance efficiency measures (speed, movement economy, errors) and ergonomic assessments are relatively well established, the evaluation of cognitive outcomes is rare. This report makes the case for assessment strategies that include mental workload measures as a way to improve training scenarios and training/operating environments. These mental workload measures can be crucially important in determining the difference between well-intentioned but subtly distracting technologies and true breakthroughs that will enhance performance and reduce stress.
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paper_title: A meta-analysis of the effects of cell phones on driver performance.

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The empirical basis for legislation to limit cell phones while driving is addressed. A comprehensive meta-analysis of the effects of cell phones on driving performance was performed. A total of 33 studies collected through 2007 that met inclusion criteria yielded 94 effect size estimates, with a total sample size of approximately 2000 participants. The dependent variables of reaction time, lateral vehicle control, headway and speed and the moderating variables of research setting (i.e., laboratory, simulator, on-road), conversation target (passenger, cell phone) and conversation type (cognitive task, naturalistic) were coded. Reaction time (RT) to events and stimuli while talking produced the largest performance decrements. Handheld and hands-free phones produced similar RT decrements. Overall, a mean increase in RT of .25s was found to all types of phone-related tasks. Observed performance decrements probably underestimate the true behavior of drivers with mobile phones in their own vehicles. In addition, drivers using either phone type do not appreciably compensate by giving greater headway or reducing speed. Tests for moderator effects on RT and speed found no statistically significant effect size differences across laboratory, driving simulation and on-road research settings. The implications of the results for legislation and future research are considered.
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paper_title: An Objective Methodology for Task Analysis and Workload Assessment in Anesthesia Providers

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BackgroundAdministering anesthesia is a complex task in which either human or equipment failure can have disastrous consequences. An improved understanding of the nature of the anesthesiologist's job could provide a more rational basis for improvements in provider training as well as the design of a
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paper_title: Multiple measures of anesthesia workload during teaching and nonteaching cases.

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UNLABELLED ::: In this study, we sought to examine several measures of anesthesia provider workload during different phases of anesthesia care and during teaching and nonteaching cases. Clinical work was assessed in real-time during 24 general anesthetics performed by consenting anesthesia providers. Workload was measured using physiological (provider heart rate), psychological (self-assessment and observer rating), and procedural (response latency to an alarm light and workload density) techniques. Clinicians' heart rates, observer and self-reported workload scores, and nonteaching workload density were consistently increased during anesthetic induction and emergence compared with maintenance. In nonteaching cases, workload density correlated with heart rate and with psychological workload. Workload density during teaching cases did not decrease during the induction and was significantly greater than during nonteaching cases. Alarm-light response latency (a measure of clinical vigilance) was significantly prolonged during the teaching compared with nonteaching cases. These results suggest that intraoperative teaching increases the workload of the clinician instructor and may reduce vigilance during anesthesia care. Additionally, multiple workload measures may provide a more comprehensive profile of the work demands of clinical cases. ::: ::: ::: IMPLICATIONS ::: Psychological, physiological, and procedural workload measures during routine general anesthesia cases documented the increased work demands of induction and emergence. Intraoperative teaching increased workload and decreased vigilance, suggesting the need for caution when educating during patient care.
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paper_title: Quantitative description of the workload associated with airway management procedures

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Abstract Study Objectives: To measure the workload associated with specific airway management tasks. Setting and Intervention: Written survey instrument. Patients: 166 Stanford University and 75 University of California, San Diego, anesthesia providers. Measurements and Main Results: Subjects were asked to use a seven-point Likert-type scale to rate the level of perceived workload associated with different airway management tasks with respect to the physical effort, mental effort, and psychological stress they require to perform in the typical clinical setting. The 126 subjects completing questionnaires (overall 52% response rate) consisted of 43% faculty, 26% residents, 23% community practitioners, and 8% certified registered nurse-anesthetists (CRNAs). Faculty physicians generally scored lower workload measures than residents, whereas community practitioners had the highest workload scores. Overall, workload ratings were lowest for laryngeal mask airway (LMA) insertion and highest for awake fiberoptic intubation. Airway procedures performed on sleeping patients received lower workload ratings than comparable procedures performed on awake patients. Direct visualization procedures received lower workload ratings than fiberoptically guided procedures. Conclusions: These kinds of data may permit more objective consideration of the nonmonetary costs of technical anesthesia procedures. The potential clinical benefits of the use of more complex airway management techniques may be partially offset by the impact of increased workload on other clinical demands.
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paper_title: Navigating towards improved surgical safety using aviation-based strategies.

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Safety practices in the aviation industry are being increasingly adapted to healthcare in an effort to reduce medical errors and patient harm. However, caution should be applied in embracing these practices because of limited experience in surgical disciplines, lack of rigorous research linking these practices to outcome, and fundamental differences between the two industries. Surgeons should have an in-depth understanding of the principles and data supporting aviation-based safety strategies before routinely adopting them. This paper serves as a review of strategies adapted to improve surgical safety, including the following: implementation of crew resource management in training operative teams; incorporation of simulation in training of technical and nontechnical skills; and analysis of contributory factors to errors using surveys, behavioral marker systems, human factors analysis, and incident reporting. Avenues and challenges for future research are also discussed.
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paper_title: Cognitive load theory in health professional education: design principles and strategies

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Context Cognitive load theory aims to develop instructional design guidelines based on a model of human cognitive architecture. The architecture assumes a limited working memory and an unlimited long-term memory holding cognitive schemas; expertise exclusively comes from knowledge stored as schemas in long-term memory. Learning is described as the construction and automation of such schemas. Three types of cognitive load are distinguished: intrinsic load is a direct function of the complexity of the performed task and the expertise of the learner; extraneous load is a result of superfluous processes that do not directly contribute to learning, and germane load is caused by learning processes that deal with intrinsic cognitive load. ::: ::: Objectives This paper discusses design guidelines that will decrease extraneous load, manage intrinsic load and optimise germane load. ::: ::: Discussion Fifteen design guidelines are discussed. Extraneous load can be reduced by the use of goal-free tasks, worked examples and completion tasks, by integrating different sources of information, using multiple modalities, and by reducing redundancy. Intrinsic load can be managed by simple-to-complex ordering of learning tasks and working from low- to high-fidelity environments. Germane load can be optimised by increasing variability over tasks, applying contextual interference, and evoking self-explanation. The guidelines are also related to the expertise reversal effect, indicating that design guidelines for novice learners are different from guidelines for more experienced learners. Thus, well-designed instruction for novice learners is different from instruction for more experienced learners. Applications in health professional education and current research lines are discussed. ::: ::: Medical Education 2010: 44: 85–93
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paper_title: Multiple Resources and Mental Workload

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Objective: The objective is to lay out the rationale for multiple resource theory and the particular 4-D multiple resource model, as well as to show how the model is useful both as a design tool and as a means of predicting multitask workload overload. Background: I describe the discoveries and developments regarding multiple resource theory that have emerged over the past 50 years that contribute to performance and workload prediction. Method: The article presents a history of the multiple resource concept, a computational version of the multiple resource model applied to multitask driving simulation data, and the relation of multiple resources to workload. Results: Research revealed the importance of the four dimensions in accounting for task interference and the association of resources with brain structure. Multiple resource models yielded high correlations between model predictions and data. Lower correlations also identified the existence of additional resources. Conclusion: The model was shown to b...
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paper_title: Methodological approaches to anaesthetists' workload in the operating theatre.

paper_content:

This review examines the basic concepts of workload and methods of measuring them. The components of anaesthetists' operating room activities, and the factors contributing to workload, are analysed using an ergonomic-based model for technological environments. The available evidence on the relationship between workload and training and supervision is presented and the effect of workload on the quality and safety of anaesthetic care is reviewed. There is, as yet, only a small body of work examining workload and its effects in anaesthesia. While studies have identified the general pattern of workload in relation to the different stages of the perioperative period, measurement, particularly of overlapping tasks, is still evolving. It is clear, however, that induction and emergence are the most intense periods of both practical and 'non-technical' aspects of work. Allocation of attention to a range of tasks simultaneously is a key characteristic of anaesthetic practice. Experienced staff appear to show 'spare capacity' in performance during routine cases, which, we suggest, allows them an attentional 'safety margin' should adverse events occur. The effects of production pressure and mental 'overload' remain speculative and so practical recommendations for anaesthetic staffing, both in terms of numbers and matching skills to surgical demand, cannot be made. The potential for delegation of tasks, for instance to non-physician anaesthetists, can also not be made on evidence-based grounds. Strategies for active management of workload may be useful in practice.
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paper_title: Maintaining competence in the field: Learning about practice, through practice, in practice

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Many of the assumptions about the "adult, self-directed learner" that form the basis of the current model of formal continuing education delivery are largely unsupported by the literature. Yet most practitioners maintain competence despite the apparent flaws in this model. After elaborating a set of problematic assumptions regarding the current construction of the self-regulating professional learner who uses formal continuing education to maintain competence, this paper explores another likely source for the learning that allows practitioners to engage in their own continuing professional development: the process of learning from their personal experiences of solving problems in their daily practice.
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paper_title: Redefining simulator proficiency using automaticity theory

paper_content:

Abstract Background Automaticity is a characteristic of expertise defined by the ability to perform a task without significant demands on attention. Our objective was to assess whether a visual–spatial task that measures spare attentional capacity would distinguish among individuals with different levels of laparoscopic expertise. Methods The performance of novices (n = 10), surgery residents (n = 9), laparoscopy experts (n = 3), and individuals previously trained (n = 7) to proficiency in laparoscopic suturing on simulators but without operative experience (trained individuals) was measured under dual-task conditions. Participants performed laparoscopic suturing for 10 minutes on a video trainer simulator using the Fundamentals of Laparoscopic Surgery suturing model (primary task) while at the same time they responded to a visual–spatial secondary task. Results Experts and trained individuals outperformed both residents and novices on the suturing task ( P P Conclusions A visual–spatial secondary task that assesses spare attentional capacity may help distinguish among individuals of variable laparoscopic expertise when standard performance measures fail to do so. Such automaticity metrics may improve current simulator training and assessment methods and warrants further investigation.
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Title: Measurement of Mental Workload in Clinical Medicine: A Review Study

Section 1: Introduction
Description 1: Introduce the concept of mental workload, its relevance in various fields, and how it can be measured in clinical settings.

Section 2: Published Evidence
Description 2: Summarize the existing studies on mental workload across different medical specialties and the methodologies used for measurement.

Section 3: Practical Considerations
Description 3: Discuss the practical aspects of measuring mental workload, including the challenges, the need for standardized measures, and the relevance of these measurements in clinical practice.

Section 4: Conclusions
Description 4: Provide a summary of key findings, recommendations for future research, and the implications of mental workload measurements for medical practice.