Re: Karl H. Pang, Diego M. Carrion, Juan Gomez Rivas, et al. The Impact of COVID-19 on European Health Care and Urology Trainees.Eur Urol 2020:78;6-8.

We commend Pang and colleagues [1] for raising concern about detrimental effects on surgical education and training during the COVID-19 pandemic. While supporting their call for the use of innovative educational solutions in these circumstances, we would like to complement this with an often overlooked and untapped, yet easily accessible and sustainable training tool: mental training. This most simple of techniques originated from aviation and has seen widespread use in similarly challenging and demanding environments such as professional sports and music, where it can increase performance by 0.5 standard deviations according to meta-analyses [2]. Almost 25 yr ago, this concept was transferred to expert surgeons [3] and has since been evaluated among competent residents and novices [4], [5]. While these studies showed significant short-term impacts, we recently explored the effect of mental training in a long-term study that included manual skills and qualitative performance measures. We found that mental training not only significantly maintained and enhanced skills in more complicated tasks over an extended period of time but also significantly impacted performance measures such as mental imagery and procedural planning [6].

Mental training in this context can be defined as cognitive rehearsal of a task in the absence of physical execution and is performed in four consecutive steps:

Identification of procedural key steps;

Relaxation techniques;

Subvocal training; and

Mental imagery.

Every task or surgical procedure can be transformed into a mental training protocol using these four components combined with experience-based notes and supplementary information. This allows every clinician to practice mental training and use their mind as a simulator [5].

Mental training for surgeons may be one of several answers to the concerns raised by the authors in these unprecedented times. Now and beyond, we encourage professional associations such as ESRU and ESU to facilitate online-based courses on the practice of mental training to help surgeons of all levels to embrace this concept.

Philippe Grange is an employee of Johnson & Johnson. The remaining authors have nothing to disclose.