Imperial College London

Mr Hemel N. Modi

Faculty of MedicineDepartment of Surgery & Cancer

Honorary Clinical Research Fellow
 
 
 
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Contact

 

hemel.modi12

 
 
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Location

 

Queen Elizabeth the Queen Mother Wing (QEQM)St Mary's Campus

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Summary

 

Publications

Publication Type
Year
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26 results found

Modi H, Singh H, Darzi A, Leff Det al., 2020, Multitasking and time pressure in the operating room: impact on surgeons’ brain function, Annals of Surgery, Vol: 272, Pages: 648-657, ISSN: 0003-4932

Objective:To assess the impact of multitasking and time pressure on surgeons’ brain function during laparoscopic suturing.Summary Background Data:Recent neuroimaging evidencesuggests that deterioration in surgical performance under time pressure is associated with deactivationof the prefrontal cortex (PFC),an area important for executive functions. However, the effect ofmultitasking on operator brain functionremains unknown.Methods:29surgical residentsperformed anintracorporealsuturing task under fourconditions: 1) self-pacedsuturing,2) time-pressured suturing, 3) self-paced suturingplus decision-making, and 4) time-pressured suturing plus decision-making. Subjectiveworkload was quantified using the Surgical Task Load Index. Technical skill was objectively assessed using task progression scores, error scores, leak volumes, and knot tensile strengths. PFC activation was measuredusing optical neuroimaging. Results:Compared with self-paced suturing, subjective workload(au)was significantly greater in time-pressuredsuturing (146.0 vs. 196.0), suturing with decision-making (146.0 vs.182.0), and time-pressuredsuturing with decision-making (146.0 vs.227.0). Technical performance duringcombined suturing and decision-making taskswas inferiortosuturing alone undertime pressure orself-paced conditions(p<0.001).Significant dorsolateral PFC (DLPFC) activations were observed during self-paced suturing, and ventrolateral PFC (VLPFC) deactivations were identified during time-pressuredsuturing. However, suturing in conjunction withdecision-making resulted in 2significantdeactivation across boththe VLPFC and DLPFC (p<0.05). Random effects regression analysis confirmed decision-making predicts VLPFC and DLPFC deactivation (z=-2.62, p<0.05).Conclusions:Performance degradation during high workload conditions is associated with deactivation of prefrontal regions important fo

Journal article

Modi HN, Singh H, Fiorentino F, Orihuela-Espina F, Athanasiou T, Yang G-Z, Darzi A, Leff DRet al., 2019, Association of residents' neural signatures with stress resilience during surgery, JAMA Surgery, Vol: 154, ISSN: 2168-6254

Importance: Intraoperative stressors may compound cognitive load, prompting performance decline and threatening patient safety. However, not all surgeons cope equally well with stress, and the disparity between performance stability and decline under high cognitive demand may be characterized by differences in activation within brain areas associated with attention and concentration such as the prefrontal cortex (PFC). Objective: To compare PFC activation between surgeons demonstrating stable performance under temporal stress with those exhibiting stress-related performance decline. Design, Setting, and Participants: Cohort study conducted from July 2015 to September 2016 at the Imperial College Healthcare National Health Service Trust, England. One hundred two surgical residents (postgraduate year 1 and greater) were invited to participate, of which 33 agreed to partake. Exposures: Participants performed a laparoscopic suturing task under 2 conditions: self-paced (SP; without time-per-knot restrictions), and time pressure (TP; 2-minute per knot time restriction). Main Outcomes and Measures: A composite deterioration score was computed based on between-condition differences in task performance metrics (task progression score [arbitrary units], error score [millimeters], leak volume [milliliters], and knot tensile strength [newtons]). Based on the composite score, quartiles were computed reflecting performance stability (quartile 1 [Q1]) and decline (quartile 4 [Q4]). Changes in PFC oxygenated hemoglobin concentration (HbO2) measured at 24 different locations using functional near-infrared spectroscopy were compared between Q1 and Q4. Secondary outcomes included subjective workload (Surgical Task Load Index) and heart rate. Results: Of the 33 participants, the median age was 33 years, the range was 29 to 56 years, and 27 were men (82%). The Q1 residents demonstrated task-induced increases in HbO2 across the bilateral ventrolateral PFC (VLPFC) and right dorsolateral P

Journal article

Modi H, Singh H, Yang G, Darzi A, Leff Det al., 2018, Neural correlates of stress resilience in the operating room, Journal of The American College of Surgeons, Vol: 227, Pages: e208-e208, ISSN: 1072-7515

IntroductionIntraoperative stressors can increase surgeons’ mental demands, precipitating technical performance decline and risking patient safety. However, the neural signatures of stress resilience among surgeons remain unknown. We aimed to compare activation in the prefrontal cortex (PFC)–important for attention and concentration–between residents demonstrating performance stability and those exhibiting performance decline when operating under time pressure.MethodsThirty-three surgical residents [median age (range) = 33 years (29 to 56), 27 males] performed a laparoscopic suturing task under ‘self-paced’ (no time restriction) and ‘time pressure’ (2-minute per knot time restriction) conditions. A composite deterioration score was calculated based on between-condition differences in technical performance, and subjects were divided into quartiles reflecting performance stability (Q1) and decline (Q4). Changes in oxygenated haemoglobin concentration (HbO2) measured at 24 prefrontal locations using functional near-infrared spectroscopy were compared between Q1 and Q4. Subjective workload was quantified using the Surgical Task Load Index (SURG-TLX).ResultsUnder time pressure, Q1 residents demonstrated task-induced increases in HbO2 in the bilateral ventrolateral PFC (VLPFC), whereas Q4 residents demonstrated HbO2 decreases. The amplitude of activation (ΔHbO2) was significantly greater in Q1 than Q4 in the bilateral VLPFC (left VLPFC: Q1=0.44±1.36μM, Q4=-0.03±1.83μM; right VLPFC: Q1=0.49±1.70μM, Q4=-0.32±2.00μM). There were no significant between-group differences in SURG-TLX scores.ConclusionsResilience to intraoperative stress is associated with sustained prefrontal activation indicating preserved attention and concentration. In contrast, sensitivity to stress is marked by prefrontal deactivation suggesting task disengagement. Future work will aim to develop interventions that recr

Journal article

Singh H, Modi HN, Ranjan S, Dilley J, Airantzis D, Yang G, Darzi A, Leff Det al., 2018, Robotic surgery improves technical performance and enhances prefrontal activation during high temporal demand, Annals of Biomedical Engineering, Vol: 46, Pages: 1621-1636, ISSN: 0090-6964

Robotic surgery may improve technical performance and reduce mental demands compared to laparoscopic surgery. However, no studies have directly compared the impact of robotic and laparoscopic techniques on surgeons’ brain function. This study aimed to assess the effect of the operative platform (robotic surgery or conventional laparoscopy) on prefrontal cortical activation during a suturing task performed under temporal demand. Eight surgeons (mean age ± SD = 34.5 ± 2.9 years, male:female ratio = 7:1) performed an intracorporeal suturing task in a self-paced manner and under a 2 min time restriction using conventional laparoscopic and robotic techniques. Prefrontal activation was assessed using near-infrared spectroscopy, subjective workload was captured using SURG-TLX questionnaires, and a continuous heart rate monitor measured systemic stress responses. Task progression scores (au), error scores (au), leak volumes (mL) and knot tensile strengths (N) provided objective assessment of technical performance. Under time pressure, robotic suturing led to improved technical performance (median task progression score: laparoscopic suturing = 4.5 vs. robotic suturing = 5.0; z = − 2.107, p = 0.035; median error score: laparoscopic suturing = 3.0 mm vs. robotic suturing = 2.1 mm; z = − 2.488, p = 0.013). Compared to laparoscopic suturing, greater prefrontal activation was identified in seven channels located primarily in lateral prefrontal regions. These results suggest that robotic surgery improves performance during high workload conditions and is associated with enhanced activation in regions of attention, concentration and task engagement.

Journal article

Singh H, Modi H, Yang G, Darzi A, Leff Det al., 2018, Impact of escalating cognitive workload and temporal demands on surgeons cognitive function, 2nd International Neuroergonomics Conference, Publisher: Frontiers Media, ISSN: 1662-5161

Conference paper

Singh H, Modi H, Darzi A, Leff Det al., 2018, Robotic Surgery Improves Technical Performance and Enhances Prefrontal Activation During High Temporal Demand, Ara Darzi

Athanasiou Award Presentation

Conference paper

Osborne-Grinter M, Patel R, Modi H, Singh H, Darzi A, Leff Det al., 2018, Enhancing Surgical Performance Through Mental Rehearsal: An fNIRS Study, society of functional Near Infra-red Spectroscopy, Biennial meeting of society of functional Near Infra-red Spectroscopy (fNIRS-2018)

Background: Mental rehearsal (MR) is the cognitive rehearsal of a skill without movement to produce genuine sensory experiences. Mandates for new approaches to surgical skill acquisition have led to increased interest in MR as a method of practical learning supplementation. However, the neurophysiological mechanisms underpinning the psychomotor benefits of MR are poorly understood.Objective: To delineate the neural mechanisms that underpin mental imagery-related improvements in surgical performance.Methods: Twelve surgical trainees performed a laparoscopic suturing (LS) task (pre-intervention) followed by randomization to either MR (n=6) or textbook reading (TR; n=6). The LS task was repeated (post-intervention). Subjective workload was quantified using the Surgical Task Load Index and Spielberg State-Trait Anxiety Index. Mental imagery ability was assessed using a mental imagery questionnaire. Continuous heart rate (HR) monitoring captured stress responses. Cortical activation was recorded with optical neuroimaging (ETG-4000, Hitachi Medical Corp., Japan). Technical skill was assessed using progression scores (au), performance scores (units) and leak volumes (mL). Results: There were no baseline differences in demographics, mental imagery ability or laparoscopic performance between the two groups. MR significantly improved post-intervention performance scores (53.10 ± 28.00 a.u. vs. -61.32 ± 40.78 a.u., p=0.04) and reduced leak volume (3.48 ±0.44ml vs. 4.81 ± 0.61ml, p=0.04) when compared to TR. MR also led to significant improvement in subjective imagery ability (41.50 ± 4.59 a.u. vs 31.17 ± 9.11 a.u, P=0.009). There were no differences in subjective or objective stress measures between the two groups. Cortical activation was defined by a significant (p < 0.05) rise in oxygenated haemoglobin with a concurrent fall in deoxygenated haemoglobin. During MR, activation was demonstrated in the left supplementary motor area (S

Conference paper

Deligianni F, Singh H, Modi H, Darzi A, Leff D, Yang GUANGet al., 2018, Expertise Related Disparity in Prefrontal-Motor Brain Connectivity, Hamlyn Symposium on Medical Robotics

Conference paper

Modi HN, Singh H, Yang G, Darzi A, Leff DRet al., 2018, Robotic surgery improves attention and concentration during times of intraoperative temporal stress, Association of Surgeons of Great Britain & Ireland International Surgical Congress, Publisher: Wiley, ISSN: 1365-2168

Conference paper

Modi HN, Singh H, Yang G, Darzi A, Leff Det al., 2017, A decade of imaging surgeons' brain function (Part II): a systematic review of applications for technical and non-technical skills assessment, Surgery, Vol: 162, Pages: 1130-1139, ISSN: 1532-7361

Background: Functional neuroimaging technologies enable assessment of operator brain function, and can deepen our understanding of skills learning, ergonomic optima and cognitive processes in surgeons. Whilst there has been a critical mass of data detailing surgeons’ brain function, this literature has not been systematically reviewed.Methods: A systematic search of original neuroimaging studies assessing surgeons’ brain function, and published up until November 2016, was conducted using Medline, Embase and PsycINFO databases.Results: Twenty-seven studies fulfilled the inclusion criteria, including three feasibility studies, fourteen studies exploring the neural correlates of technical skill acquisition, and the remainder investigating brain function in the context of intraoperative decision-making (n=1), neurofeedback training (n=1), robot-assisted technology (n=5), and surgical teaching (n=3). Early stages of learning open surgical tasks (knot-tying) are characterised by prefrontal cortical (PFC) activation which subsequently attenuates with deliberate practice. However, with complex laparoscopic skills (intra-corporeal suturing), PFC engagement requires substantial training and attenuation occurs over a longer time-course, following years of refinement. Neurofeedback and interventions that improve neural efficiency may enhance technical performance and skills learning. Conclusions: Imaging surgeons’ brain function has identified neural signatures of expertise which might help inform objective assessment and selection processes. Interventions which improve neural efficiency may target skill-specific brain regions and augment surgical performance.

Journal article

Modi HN, Singh H, Yang G, Darzi A, Leff Det al., 2017, Neural markers of sensitivity to intraoperative temporal stress in surgeons, Mexican Symposium on NIRS Neuroimaging, Publisher: MEXNIRS

Conference paper

Ranjan S, Modi HN, Singh H, Darzi A, Leff Det al., 2017, The impact of time pressure on prefrontal cortical activation and technical performance during robotic suturing, 11th London Surgical Symposium

Conference paper

Ranjan S, Modi HN, Singh H, Darzi A, Leff Det al., 2017, The impact of 3D vision on prefrontal activation and technical performance during a robotic suturing task, 11th London Surgical Symposium

Conference paper

Modi HN, Singh H, Yang G, Darzi A, Leff Det al., 2017, A decade of imaging surgeons' brain function (Part I): terminology, techniques and clinical translation, Surgery, Vol: 162, Pages: 1121-1130, ISSN: 1532-7361

Functional neuroimaging has the potential to deepen our understanding of technical and non-technical skill acquisition in surgeons, particularly as established assessment tools leave unanswered questions about inter-operator differences in ability that seem independent of experience. In this first of a two-part article, we aim to utilise our experience in neuroimaging surgeons to orientate the non-specialist reader to the principles of brain imaging. Terminology commonly used in brain imaging research is explained, placing emphasis on the “activation response” to a surgical task and its effect on local cortical haemodynamic parameters (neurovascular coupling). Skills learning and subsequent consolidation and refinement through practice lead to reorganisation of the functional architecture of the brain (known as “neuroplasticity”), evidenced by changes in the strength of regional activation as well as alterations in connectivity between brain regions, culminating in more efficient use of neural resources during task performance. Currently available neuroimaging techniques that either directly (i.e. measure electrical activity) or indirectly (i.e. measure tissue haemodynamics) assess brain function are discussed. Finally, we highlight the important practical considerations when conducting brain imaging research in surgeons.

Journal article

Singh H, Modi HN, Yang GZ, Darzi A, Leff DRet al., 2017, “Losing Your Nerve in the Operating Room” – Prefrontal Attenuation is Associated with Performance Degradation under Temporal Demands, 10th Hamlyn Symposium on Medical Robotics, Pages: 55-56

Conference paper

Modi HN, SIngh H, Orihuela-Espina F, Athanasiou T, Fiorentino F, Yang GZ, Darzi A, Leff DRet al., 2017, Temporal stress in the operating room: brain engagement promotes "coping" and disengagement prompts "choking", Annals of Surgery, Vol: 267, Pages: 683-691, ISSN: 1528-1140

Objective:To investigate the impact of time pressure (TP) on prefrontalactivation and technical performance in surgical residents during a laparo-scopic suturing task.Background:Neural mechanisms enabling surgeons to maintain perform-ance and cope with operative stressors are unclear. The prefrontal cortex(PFC) is implicated due to its role in attention, concentration, and perform-ance monitoring.Methods:A total of 33 residents [Postgraduate Year (PGY)1 – 2¼15,PGY3– 4¼8, and PGY5¼10] performed a laparoscopic suturing taskunder ‘‘self-paced’’ (SP) and ‘‘TP’’ conditions (TP¼maximum 2 minutes perknot). Subjective workload was quantified using the Surgical Task LoadIndex. PFC activation was inferred using optical neuroimaging. Technicalskill was assessed using progression scores (au), error scores (mm), leakvolumes (mL), and knot tensile strengths (N).Results:TP led to greater perceived workload amongst all residents (meanSurgical Task Load Index score SD: PGY1 – 2: SP¼160.3 24.8 vs TP¼202.1 45.4,P<0.001; PGY3 – 4: SP¼123.0 52.0 vs TP¼172.5 43.1,P<0.01; PGY5: SP¼105.8 55.3 vs TP¼159.1 63.1,P<0.05).Amongst PGY1– 2 and PGY3– 4, deterioration in task progression, errorscores and knot tensile strength (P<0.05), and diminished PFC activationwas observed under TP. In PGY5, TP resulted in inferior task progression anderror scores (P<0.05), but preservation of knot tensile strength. Furthermore,PGY5 exhibited less attenuation of PFC activation under TP, and greateractivation than either PGY1 – 2 or PGY3 – 4 under both experimental con-ditions (P<0.05).Conclusions:Senior residents cope better with temporal demands and exhibitgreater technical performance stability under pressure, possibly due to

Journal article

Modi HN, Leff DR, Singh H, Yang GZ, Darzi Aet al., 2016, Cognitive mechanisms of workload-related performance decline in surgical residents, American College of Surgeons Clinical Congress 2016, Publisher: Elsevier, Pages: S124-S125, ISSN: 1072-7515

Conference paper

Modi HN, Singh H, Athanasiou T, Yang GZ, Darzi A, Leff Det al., 2016, Random effect modelling of prefrontal cortical haemodynamics to determine the influence of surgical expertise on executive control during temporal stress in the operating room, The Society for Functional Near-Infrared Spectroscopy, Publisher: fNIRS

Conference paper

Modi HN, Leff D, Singh H, Darzi Aet al., 2016, Time in training does not predict performance deterioration under pressure, Association for Medical Education in Europe, Publisher: AMEE

Conference paper

Modi HN, Leff DR, Singh H, Darzi Aet al., 2016, Temporal Demands Increase Workload and Degrade Surgical Performance, International Surgical Congress of the Association of Surgeons of Great Britain and Ireland, Publisher: Wiley, Pages: 52-53, ISSN: 1365-2168

Conference paper

Modi HN, Singh H, Yang GZ, Darzi A, Leff DRet al., 2016, “Coping or choking”: sustained prefrontal activation and improved laparoscopic performance under time pressure, 9th Hamlyn Symposium on Medical Robotics

Conference paper

Modi HN, Singh H, Orihuela-Espina F, Yang G, Darzi A, Leff Det al., 2016, Cortical haemodynamic changes associated with high and low cognitive demand in surgeons, 22nd Annual Meeting of the Organisation for Human Brain Mapping, Publisher: Organization for Human Brain Mapping

Conference paper

Singh H, modi H, Yang GZ, leff D, darzi Aet al., 2016, A surgeon’s brain switch: cortical dynamics of cognitive load in surgeons, Publisher: Graz University of Technology, Pages: 163-163

Conference paper

Modi HN, Leff DR, Singh H, Darzi Aet al., 2016, The influence of cognitive load on technical ability among surgical trainees, Association of Surgeons in Training International Conference

Conference paper

Modi HN, Singh H, Leff DR, Yang GZ, Darzi Aet al., 2015, “Blushing when the heat is on”: can cognitive load in the surgeon’s brain be captured?, 9th London Surgical Symposium

Conference paper

Modi HN, Smith S, 2015, Effective supervision in surgical training: a phenomenological analysis of trainees’ experiences, Association for Medical Education in Europe

Conference paper

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