The Flush Model: A Novel Framework to Manage Surgeons' Mental Fatigue and Cognitive Load

Mental fatigue significantly impairs surgeons' cognitive performance, compromising patient safety. However, surgical practice lacks an integrated framework to understand and mitigate this cognitive strain effectively.

We propose adapting the Flush model, initially developed for endurance sports, to surgical settings. This model conceptualizes mental fatigue through a dynamic analogy of a water tank composed of 4 main components: perceived fatigue (ballcock), fatigue accumulation (filling rate), fatigue recovery (drain rate), and a safety margin (security reserve). We detail how intrinsic cognitive load, extraneous stressors, physiological and psychological factors, and circadian influences collectively drive mental fatigue accumulation.

The Flush model clarifies how mental fatigue fluctuates during surgical procedures and highlights practical recovery methods such as brief mindfulness interventions, microbreaks, cognitive offloading, and ergonomics adjustments. It emphasizes maintaining a cognitive safety reserve to safeguard against errors during critical surgical phases, providing surgeons with actionable strategies to manage fatigue in real time.

We recommend empirical validation through real-time monitoring using physiological measures (eg, heart-rate variability, pupillometry) coupled with subjective assessments (eg, NASA Task Load Index, Surgery Task Load Index). Integrating Flush principles into surgical training, simulation programs, and institutional policies could foster a culture prioritizing cognitive performance and patient safety.

The Flush model provides a comprehensive, intuitive framework for understanding and addressing surgeons' mental fatigue. Its implementation promises to enhance cognitive resilience, reduce surgical errors, and improve both patient outcomes and surgeon well-being.