Introduction: Flow is the optimal mental state where individuals experience the highest focus and are fully absorbed in a task. Furthermore, research has shown that Flow predicts performance outcomes in several disciplines. Brain-Computer interfaces and Heart Rate sensors have shown approaches to distinguish Flow with electroencephalography (EEG) and Heart Rate (HR). Individuals who performed significantly better in specific tasks and were in Flow showed increased theta activity (4-7 HZ) in their EEG spectrum and lower HR. Performance outcome is crucial in surgery, and achieving Flow could enhance physicians' performance significantly. Our study aims to investigate these markers during virtual reality (VR) surgery training to provide objective measurements of peak performance. Methods: We conducted the study with 20 urologic surgeons. We used a wireless EEG headband to record theta activity. HR was measured with a wireless HR sensor. The VR training was performed on the intuitive DaVinci Skills Simulator for robotic-assisted surgery. After completing the surgical tasks, the Flow Short Scale (FSS) was applied to measure the subjective Flow experience. Two VR tasks were performed on the simulator followed by the FSS. This procedure was repeated three times. Our primary objective was to investigate differences between high and low performers, their EEG output, HR and FSS scores. To test the different models, we conducted Generalized Estimating Equations Models (Wald test). Additionally, Spearman's Rank Correlation was computed to detect associations between the variables. Results: We found that high performers had a significantly higher theta activity than low performers with W(2)=7.29, p = .026. In Addition, we observed a significantly lower HR among high performers than among low performers, with W(1)=9.86, p = .007(MD = 10.21, SD = 3.33). Furthermore, we detected a positive correlation between VR surgery scores and subjective flow experience within high performers with r(10) = 0.63, p = .048. Conclusions: Our findings indicate that surgeons who achieved higher performances showed more theta activity in their EEG spectrum and lower HR than surgeons with lower performance during VR surgeries. These findings highlight the importance of the ability to calm one's physiology as a predictor of performance outcomes. These results may lead to specific bio- and neurofeedback training protocols for surgeons to enhance their performance, accelerate the learning curve and reduce their arousal level during challenging intraoperative situations. SOURCE OF Funding: UZH Sc. Foundation
