You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

‘My Mental Toughness Manifesto’ Part 2: PRACTICE

15 Mar, 17 | by rlloyd

Screen Shot 2017-03-06 at 15.55.21

In MMTM Part 1, two-step cognitive appraisals were explained. This process dictates whether one enters a challenged or threatened mindset in the event where an immediate performance is required under acute stress.

Feeling challenged, of course, is one of the two chief components of a mentally tough individual.

“I am 100% committed”

“I feel challenged”

In this post, we will explore principles which must be incorporated in one’s ‘practice‘ (i.e. training) regime, to increase a sense of confidence in one’s skillset. The confident individual will always be more likely to appraise a scenario as challenging as opposed to threatening.

Paradigm shift alert: When practicing, specific skill development must be prioritised over knowledge-base widening. This, of course, sharply contrasts with the traditional approach to medical training. New theoretical concepts seem less abstract and will always be absorbed more rapidly when they fit into the mental scaffolding built by focusing on skill development.

In an ideal world, all clinicians, across the spectrum of specific role and geographic location, would get regular high-fidelity simulation training sessions, supervised by master educators. Of course, this isn’t feasible in even the richest healthcare systems; and the reality is that all types of supervised training (other than weekly death-by-PowerPoint didactic teaching) become increasingly rare the more senior you become.

Therefore, one must take ownership over one’s own practice, and be relentless in the pursuit of ultimate confidence in one’s skillset. This will be achieved through immersiondeliberate practice, and visualisation.

Immersion

“Discipline equals freedom”

Jocko Willink, Navy SEAL Commander

My definition of professional ‘immersion’ is regular engagement with one’s craft outside of working hours. The abundance of free online medical education (FOAMed) resources makes this process exceptionally easy and enjoyable. With availability/access to excellent content no longer an issue (unlike the olden days where you had to sift through dusty textbooks, and YouTube hadn’t yet been invented), the only obstacle standing in the way of adequate immersion is having the discipline to allocate time to it.

Too often, clinicians assume they are advancing their expertise, and fine-tuning performance standards, purely by attending work – clocking in and clocking out, going through the motions on the shop floor, and then completely disengaging during free time. This is occupational autopilot. And it is dangerous.

Screen Shot 2017-03-14 at 20.33.35Occupational autopilot predisposes clinicians to flounder during a crisis, because the mind stiffens when seldom fed new information. For example, the disengaged anaesthetist who rarely ventures far from uncomplicated elective orthopaedics will be flummoxed by the surprise grade 4 intubation. Despite being entirely competent enough to weather the storm, he/she will fall easily into the clutches of the threat mindset and spectacularly fail the patient in that rare moment, largely because of their lack of engagement with the broader landscape of their chosen pursuit.

The ability to think laterally, employ techniques that might be ‘rusty’ or never performed before (e.g. surgical cricothyroidotomy), and trust one’s own clinical judgement, can only occur seamlessly if you have adequately immersed yourself in the educational resources and evolving narrative of your vocation.

Of course, immersion in specific resources to improve an isolated skill is crucial if weakness is identified (a principle of ‘deliberate practice’ – see below). But it’s the habitual (daily) general immersion, with no specific agenda, that is a key characteristic of the dedicated professional whose identity is embedded in his or her craft. Immersion isn’t a training methodology – it is a lifestyle decision. It ensures currency is maintained, and nurtures a fertile cognitive environment, mandatory for yielding the acrobatics and improvisation required during a crisis.

Deliberate Practice

“Skill is only developed by hours and hours of beating on your craft.”

Will Smith, actor

Deliberate practice describes a common set of principles which should form the framework of every training session [1].

Every time you practice, your sole mission is to improve. You should constantly be asking yourself the question: “How can I do this better?”.

A specific component of a chosen skill is isolated – one that you are poor at or can’t do – and then subjected to specific training exercises and repetitions (‘drilling’).

The core principles of deliberate practice:

  1. specific, measurable goal must be established for the session. Vague overall performance targets like ‘succeed’ or ‘get better’ mean nothing.
  2. Be maximally focused on improvement during practice. It must be intense and uninterrupted. Put your electronic device away.
  3. Receive immediate feedback on your performance. Without it, you won’t be able to figure out what you need to modify or how close you are to achieving your goal.
  4. Exit your comfort zone. Push yourself to the edge of what you are capable of. Don’t be afraid of failure – it signposts the path to progression.

IdScreen Shot 2017-03-14 at 20.35.09eally, a supervisor should be present to guide training, and give immediate feedback. When this isn’t available (which will be most of the time for the majority of clinicians), video footage of the skill being performed/taught is a decent substitute. You can compare your own repetitions to the video subject, and ‘self-police’ your training progress. The plethora of FOAMed video content makes this comfortably achievable.

Human nature dictates that we gravitate towards training skills that we are already proficient at, and neglect areas outside our comfort zone. Why? It’s much more satisfying to feel like you are ‘nailing’ something. DO NOT be enticed into that trap – the significant gains exist where there is most discomfort and least enjoyment. What is enjoyable, is the feeling that you are moving forward and advancing your overall proficiency.

Regular re-visiting of skills that have laid dormant for a while (either in practice or in the field) is essential for avoiding skill fade. This habitual ‘spaced repetition’ deeply embeds a skillset into our mental scaffolding, and makes it far more likely to be retrievable under acute, severe stress.

Here is a previous blog which covers deliberate practice in a little more detail.

Visualisation

“In my view, the answer is to use the highest fidelity simulator in the universe – the human brain”

Cliff Reid, Emergency Physician, Sydney HEMS

Despite it being our most powerful and adaptive weapon, we routinely fail to utilise our brain as a training gadget. When physically practicing, our minds are engaged, but (naturally) we conceptualise the process as being entirely external. Our conscious focus is largely zoned in on body positioning or equipment handling, making it easy to forget our brain is the anatomical structure in the driving seat.

tigerwoodsvisualization

Visualisation (or ‘mental practice’/’mental rehearsal’/’imagery’) is the process of consciously playing a mental ‘video’ of a task or scenario from the perspective of one’s own eyes. In other words, one thinks about doing something, step by step. Despite no physical engagement, one is activating the very same neural circuitry as when performing the skill for real, and if done effectively, it reinforces skill-related mental scaffolding, just like deliberate practice [2, 3]. It enhances clarity and speed of thought during the moment of truth.

Much like the concept of mental toughness itself, visualisation can get routinely dismissed as a vague, abstract, somewhat hippyish concept, with little scientific credibility. If that is your opinion, you are sorely mistaken and missing a huge opportunity. The evidence-base is abundant across a wide spectrum of human endeavour, with perhaps the most high profile examples found in the results-driven world of elite sport [4, 5, 6]. Desperate for the edge over equally motivated competition, you would be hard pushed to find an upper echelon-worthy individual or team not dedicating a considerable portion of their training schedule to mental practice. Put simply, it is considered pivotal to producing the goods by folk who earn their living making us say ‘WOW’. When the Federers, Mcilroys, and Bradys of this world consider it indispensable, then frontline healthcare, an equally performance-centric game, should be paying attention.

Vivid realism is crucial for the process to be effective. You need to feel it as well as see it. The PETLEPP mnemonic is a useful guide [7]:

Physical – What are you holding? What are you wearing? What are you smelling?
Environment – What are your surroundings? It is essential to imagine yourself in the environment where you will be performing (i.e. your usual workplace).
Type –Imagery must be specific to your role and responsibility.
Timing – Given the time critical nature of acute care, imagery must take place in ‘real time’.
Learning – Content should evolve with learning. The cognitions and feelings experienced will change as the individual improves.
Emotion – Imagine yourself acutely stressed, but in the challenge mindset. Total ‘calm’ is not realistic and, therefore, not useful.
Perspective – Feel and see from your own perspective (i.e through your own ‘eyes’).

The unique selling point of visualisation when compared to other practice modalities is its malleability. Using your imagination to conjure up potential curveballs and banana skins is a very effective method for finely sharpening routine skills and processes where there may be a tendency to get complacent. Play the ‘what if’ game:

“What if I had to perform an RSI on a 300kg patient with a receding chin? What extra precautions should I take?”

“What if whilst I was putting in a right IJV central line, the patient became hypotensive and the oxygen saturations dropped to 70%? What should my next steps be?”

“What if I was the trauma team leader for a penetrating chest trauma case and suddenly the patient lost output?”

It’s also a perfect strategy for shoring up one’s procedural routine for exceptionally rare events, such as the emergency thoracotomy or perimortem Caesarian section. Procedures like that would be uneconomical, and logistically impossible, to repetitively practice on mannikins/cadavers. Regular and structured mental practice is therefore a must for emergency providers who genuinely want to be able to tackle everything thrown at them. It is impossible to predict what is coming through the resus doors, but when you have seen it all in the simulation lab between your ears, you will be ready.

This technique isn’t limited to skills training; it can be applied on a broader, more personal level as well. It can galvanise the spirit, and ignite the passion for positively affecting the world through your job – a trait abundant in all of us deep down. Regularly visualise yourself returning home at the end of a shift, mission, or deployment with that beautiful sense of victory and euphoria that washes over when you know you’ve performed well. See yourself overcoming every obstacle thrown at you on duty, and always able to access clarity of thought, and the best of your ability, when it really counts.

Capture yourself in the career trajectory exactly as you have always dreamed it, regardless of how far away you currently feel. If you have the imagination to dream, and the courage to believe that your vision is possible, it will make you hungrier to strive for it. Every training session will be laced with boundless intent, and in time, your mental movie will become a reality.

Summary

Effective practice is about building confidence, so that when a performance is required, the challenge mindset is achieved.

Immersion in your craft safeguards against occupational autopilot, and fosters a healthy cognitive environment for high performance.

When training specifics, fully embracing the principles of deliberate practice is the only gateway to expert-level skills.

Visualisation, when maximally vivid and performed in a structured fashion, can prepare you for anything. Never underestimate the training-tool that is your mind.

Building mental toughness isn’t easy, but your patients deserve it. No-one will do it for you. Get after it.

References

  1. Peak: Secrets From the New Science of Expertise. Anders Ericsson and Robert Pool.
  2. Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business.
  3. Mike Lauria. EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria. EMCrit Blog. Published on February 21, 2017. Accessed on March 13th 2017. Available at [https://emcrit.org/blogpost/ehpr-part-5-using-mental-practice-visualization-exercises-mike-lauria/].
  4. Feltz DL, Landers The effects of mental practice on motor skill learning and performance: A meta- analysis. Journal of Sport Psychology. 1983;5(1):25-57.
  5. Mental Training for Peak Performance. Steven Ungerleider and Nick Bollettieri.
  6. Sports visualisation: how to imagine your way to success. Mark Bailey, The Telegraph.
  7. Holmes PS, Collins DJ. The PETTLEP Approach to Motor Imagery: A Functional Equivalence Model for Sport Psychologists. J Appl Sport Psychol. 2001; 13(1): 60-83.

‘My Mental Toughness Manifesto’ Part 1: Understanding Cognitive Appraisals

5 Mar, 17 | by rlloyd

It has been an exciting period for me recently. Last month I was at the International Special Training Centre (ISTC) in Pfullendorf, Germany, where I had the honour of speaking to a group of Special Operations Combat Medics in-training from eleven nations across NATO. Staying at the base, meeting the guys, and contributing to their fantastic 26-week course was an unforgettable experience, and without a doubt my most proud achievement to date.

Why me? Last year I blogged/podcasted for St. Emlyn’s about my lively experience working in a South African Township Emergency Department, at Khayelitsha District Hospital. Luckily for me, a course faculty member from the ISTC stumbled across this work and thought I might have something to offer a group of warrior medics.

If you haven’t read the original blog, I would advise that you do before proceeding; the credibility of what follows hinges on its predecessor.

I was tasked with providing a session that tackled human performance optimisation. Through four separate 20-minute lectures, I delivered a package of strategies for ‘Building Mental Toughness’.

This post is a summary of my first lecture at the ISTC, and is the first instalment of a four-post series. I am making a call-to-arms: frontline healthcare providers must start prioritising performance optimisation strategies.

This is my ‘Mental Toughness Manifesto’.

What is Mental Toughness?Roger-Federer-of-Switzerl-007

Traditionally, it’s a term synonymous with the sports world. It is therefore often ignored or laughed off as meaningless cliché, particularly by performers in healthcare – a ‘serious’ field. In my opinion, this represents a glaring missed opportunity.

A mentally tough individual is consistently able to produce desirable performances during moments of high stress; an undeniably crucial trait for those operating in high octane environments, not least the resus room, prehospital environment, or the realm of combat.

By accurately identifying the specific components of mental toughness, we can work on strengthening it through focused training and attitude adjustments. During a stressful, high stakes scenario where a performance is immediately required, (having interrogated the literature [1]) I believe you are mentally tough if able to state the following:

“I am 100% committed”

“I feel challenged”

Commitment to one’s overall goal is critical, but should be a foregone conclusion. A trauma team leader, flight paramedic, or special operations combat medic, should be inherently committed to their job because what they do is of indisputable importance – they deal in the currency of human life. Also, they will have had to demonstrate commitment whilst climbing their respective professional ladders, via examination and selection processes. So, the first half of the battle – ‘being 100% committed’ – is the easy bit.

Feeling ‘challenged’, as opposed to feeling threatened by a stressful scenario, is more complicated. This requires confidence in one’s skillset, and a feeling of control over one’s emotional arousal.

Cognitive Appraisals

It is imperative to appreciate the nuances of acute stress, and how it influences our physiology and cognition.

When an individual is faced with a situation which threatens an important goal (like staying alive, or keeping someone else alive), an immediate two-step cognitive appraisal takes place [2, 3]:

If personal resources are deemed sufficient to meet the demands of the scenario, the ‘challenge appraisal’ ensues. One feels positively energised (‘pumped up’), there is a sense of high self-esteem, and one will view the situation as an opportunity to capture a victorious moment. It is what athletes call being ‘in the zone’. There is physiological stress via activation of the sympathetic nervous system, but control of task-specific motor skills and cognition remains intact.

If the demands outweigh available resources, a ‘threat appraisal’ takes hold. In addition to the sympathetic nervous system response, the hypothalamic-pituitary (HPA) axis activates, triggering the release of cortisol. This cortisol ‘dump’ is a relic from our days as primal hunter-gatherers. It readies the mind and body for instant, evasive action (like running away from a predator), which is, of course, suboptimal when a skilled and complex performance is immediately required.

Threat appraisals narrow our auditory and visual perception, minimise our mental ‘bandwidth’, increase our sense of fear (via its effect on the amydala), erode our short-term memory (hippocampus), and obliterate our capacity for rational judgement (prefrontal cortex) [4].

Need convincing? Watch the video below for an armchair threat appraisal…

 

The psychological literature has consistently demonstrated that high serum cortisol is associated with impaired performance, over a wide range of human pursuit [4, 5]. What becomes clear, therefore, is that performance optimisation centres around this two-step cognitive appraisal process. By using strategies to modify one’s perception of the immediate demands and available resources, we can convert threat appraisals to challenge appraisals, and in doing so, harness the power of the sympathetic nervous system, avoiding HPA axis-mediated self-sabotage.

I will propose seven strategies, over three phases of the game (the ‘practice’, ‘perform’, and ‘process’ phases), designed to favourably modify our perceptions during the cognitive appraisal process. The aim is to build the challenged mindset, resulting in a mentally tougher performer, better equipped for saving lives.

Stay tuned for the next instalment.

Robert Lloyd
@PonderingEM

References

  1. Mike Lauria. Imperturbability: William Osler, Resilience, and Redefining Mental Toughness by Mike Lauria. EMCrit Blog. Published on February 3, 2016. Accessed on February 24th 2017. Available at [https://emcrit.org/blogpost/imperturbability-william-osler-resilience-and-redefining-mental-toughness/].
  2. Tomaka, J., Blascovich, J., Kelsey, R. M., & Leitten, C. L. (1993). Subjective, physiological, and behavioral effects of threat and challenge appraisal. Journal of Personality and Social Psychology, 65, 248-260.
  3. LeBlanc, V.R., The effects of acute stress on performance: implications for health professions education. Acad Med, 2009. 84(10 Suppl): p. S25-33.
  4. Scott Weingart. Podcast 177 – Chris Hicks on the Fog of War: Training the Resuscitationist Mindset. EMCrit Blog. Published on July 11, 2016. Accessed on February 24th 2017. Available at [https://emcrit.org/podcasts/chris-hicks-fog-of-war/].
  5. How stress affects your brain – Madhumita Murgia, TED Ed

*This post has also been published on the Pondering EM blog.

Primary Survey March 2017

23 Feb, 17 | by scarley

It’s March 2017 and time for a quick review of the best of the EMJ this month

Under pressure: does cricoid improve laryngoscopy?

Whether or not we should use cricoid during emergency intubation is fast becoming one of the greatest modern controversies in Emergency Medicine. While we await data from randomised controlled trials, in this month’s issue Caruana et al have provided some important new evidence. In a retrospective analysis of 1195 patients undergoing pre-hospital intubation, cricoid pressure was not found to be associated with difficult laryngoscopy. After propensity score matching, there were no apparent differences in the incidence of complications with or without the use of cricoid pressure, other than an increase in the proportion of patients sustaining airway trauma when cricoid pressure was used. Ultimately we now have further reason to question the routine use of cricoid pressure, but is it sufficient to change your practice?

Statistics made much easier!

Reading the phrase ‘propensity score matching’ may have just made you feel a little uncomfortable. If so, you’re not alone. Most emergency physicians could do with a little help when it comes to interpreting some of the more complicated statistical analyses we encounter in the literature. If you feel that way, I’m sure you’ll be pleased to see that this month we have the first in an occasional series of articles on statistical concepts that go beyond the basics. These articles aim to provide a helpful tutorial to readers to increase their skills of critical appraisal for the future. To help illustrate the concepts, we will link them to original articles that we publish. This month, we’ve linked to the work by Caruana et al, which is free to access as the editor’s choice.

Who calls ambulances and doesn’t wait?

Most of us can appreciate that calling for an emergency ambulance is not to be taken lightly. When emergency services are facing severe and increasing pressure, it can be extremely frustrating to observe that some patients arrive in the Emergency Department by ambulance but don’t wait to be seen. In this issue, Doupe et al explore the characteristics of patients who do just that. Compared with other patients, they found that patients who called an ambulance and did not wait were more likely to have a history of substance abuse ad to live in low income areas. Identifying the characteristics of patients who exhibit this behaviour will help emergency physicians to create individual management plans to deal with apparently unhelpful patterns of seeking healthcare.

A new device to help metrics for ED weighting

Rapidly and accurately estimating the weight of children presenting to the Paediatric Emergency Department is highly important for drug dosing but often challenging. Emergency physicians commonly use formulae or aids such as the Broselow tape. This month, Jung et al report on the accuracy of a novel ‘rolling tape’ electronic device with wireless transmission. They demonstrate that its use enabled faster and more accurate weight estimation than the Broselow tape. However, they go further still: using the rolling tape led to faster orders for resuscitation drugs and defibrillation in cardiac arrest. Could this revolutionise how we measure patients’ weight in the Paediatric Emergency Department?

The trajectory of an academic emergency physician

If you’re a research active emergency physician, you may be interested in tracking your academic progress in relation to other emergency physicians. Is your progress fast or slow? In this issue, Miro et al explore whether we can develop a guide to the progress of researchers in Emergency Medicine. They tracked the h-index of a selected group of academic emergency physicians. The h-index tries to combine an author’s impact with their productivity. If an author has, for example, 5 articles that have been cited 5 times or more, then their h-index is 5. Miro et al have derived a formula to track the rise in h-index for ‘fast’, ‘medium’ and ‘slow’ growth academics. Where do you fit in? Don’t be discouraged, though. All the authors included in this sample were highly reputable academic emergency physicians. Even those in the ‘slow growth’ category may therefore be elite researchers. You may, however, find that this article spurs you on!

Can doctors measure pain in children?

Brudvik et al report a fascinating study in which they asked children to score their pain in the Paediatric Emergency Department, while doctors and parents were asked to estimate the score. How do you think we did? Read the full article to find out the detail, but you may be surprised to find out how much we under-estimate pain and how often we withhold analgesia, even for children with severe pain. It’s a sobering reminder that the pain of an individual is a very personal experience and cannot be accurately measured by others.

vb

Rick Body

PDF

http://dx.doi.org/10.1136/emermed-2016-206657

Are nurses always right?

15 Feb, 17 | by cgray

Are nurses always right?

As a junior doctor, I have had, and still have some fantastic senior colleagues to work with, who generally give important and valuable advice. Over the placements and years, their advice is slowly turning me into the doctor that I aspire to be, an amalgamation of all the good bits from every doctor I have worked with so far along the way. I say doctor, but really I’m talking about all the other people that play a part in the hospital experience. Physiotherapists, pharmacists, health care assistants, porters, and so many more. Most of all, the many brilliant nurses I’ve had the pleasure of working alongside.

When I first started out as a doctor, the single biggest piece of advice that was given to me, and that still holds true today as one that I pass on to those unlucky enough to be my juniors, is to listen to the nurses. Make friends with the nurses. Don’t get on their bad side. Pay attention to what they say. That advice has saved me and saved my patients more times than I can count.

Because, nurses are always right. Aren’t they?

It’s a brave team that would design a study to pit nurses against a scoring tool, but that’s exactly what Allan Cameron and team from Glasgow have been up to. The Glasgow Admission Prediction Score (GAPS) was developed to estimate the probability of a patient being admitted, based on data collected at triage such as the patient’s age, early warning score, and triage category. The tool has been validated with good results, and could be used to help to optimise flow within the ED through early identification of those more likely to need a hospital bed.

This study, published in the January EMJ, aimed to compare GAPS to the triage nurses’ gestalt on likelihood of admission. To assess the latter, a visual analogue scale (VAS) was used, onto which triage nurses would mark how certain they were of patient admission/discharge. Previous studies on the topic have shown that when nurses are confident of the outcome, they’re usually right, and this study was no different. As always, we’d recommend you take a look at the paper itself to draw your own conclusions from the results.

3844 attendances to a single emergency department were studied, however a portion were allocated direct to a minors or resuscitation area, bypassing triage, and further patients were excluded from being under 16 or leaving before treatment was complete. Only 9 patients out of the 2091 that were triaged had insufficient data completion, which is a respectable figure. Of the 1829 attendances suitable for inclusion, 745 were admitted (40.7%), which seems high, however as stated this did not include a large number of minors patients who were more likely to have been discharged.

Nurse gestalt was found to be more sensitive than GAPS (81.2% vs 71.8%) but less specific (77.4% vs 86.6%). There was no correlation between nurse seniority and accuracy of predictions. Whilst the GAPS was more centrally distributed, results from the VAS showed peaks at 0-5% and 95-100% certainty of admission. This was the case for 781 patients. In these patients, nurses performed significantly better than GAPS, correctly predicting outcome in 92.4% (722). Excluding these patients though, GAPS provided a more accurate assessment.

In practice, the team found that the most accurate way to predict likelihood of admission was GAPS, but with the triage nurses able to override the tool where they were confident (>95%) as to whether the patient would be admitted or discharged. The authors admit that more work is needed, but maybe we’ll see admission prediction scores in use in the future.

Interestingly, there is no mention on whether those patients discharged home were followed up to see if any were admitted in the following days. Maybe the nurses’ gut feeling wasn’t wrong after all…

vb

C
@cgraydoc

BBC visit UK emergency department and experience Winter pressures

7 Feb, 17 | by scarley

It’s not really news that UK Emergency departments are under pressure, but those realities are often hidden from the general public. However, in the last week the BBC was granted access to the Royal Blackburn hospital to see first hand how it feels to deliver emergency care in an overcrowded environment.

Follow the link below to see the BBC review.

http://www.bbc.co.uk/news/health-38885775

vb

S

The One-Upping Blind spot.

2 Feb, 17 | by scarley

Sometimes you see things on twitter that upset you. This week I noticed this post from the excellent Shaun Lintern on ‘one-upping’ in hospitals. It’s not a phrase I’ve heard before but it essentially means putting an extra patient on wards above their intended capacity.

Ruth May is the executive director of nursing for the NHS Improvement agency. She is quoted as saying that one upping is not acceptable and that it poses a significant risk to patients. There is little to argue with this but stop and think, what are the consequences for the whole system if one area declines to accept any risk? Does the risk vanish, or does it simply move elsewhere? I suspect that you, like me know that it is the latter.

If one upping is unacceptable does NHS Improvement have any idea what it’s like to work in a UK ED at the moment? Never mind one upping, try 10,11,12,13,14,15 upping your trolley patients. It is so common as to be routine practice in the UK.

Those numbers do not take account of the patients in the waiting rooms who should be on trolleys, but who are on chairs as we’ve run out of trolleys for them to lie on. Is it acceptable to have to give IV opiates to a patient sat on a chair in a corridor with renal colic? Of course not, but that real example is a manifestation of what overcrowding means. It’s incredibly risky for patients as we know that overcrowding causes increased numbers of deaths. Make no doubt about it, overcrowding causes death and disability in our patient populations in the ED.

Ruth May does not state whether her comments apply to the ED and I’m sure she knows about EM overcrowding, but her comments are likely to prevent the sharing of risk across hospitals and services. This could lead to more harm as we know that sharing risk is a positive patient safety move. You should be familiar with Full capacity protocols which are designed to share the load and to avoid the harms that overcrowding causes, but they are yet to catch on in the UK.

Also see www.hospitalovercrowding.com

How on earth can it then be logical to concentrate all that risk in one place, the ED, rather than spread the risk across wards and departments? How can it be wise to ask my team to look after multiple patients on trolleys in corridors as opposed to asking a number of wards to take one extra patient.

It’s illogical, unsafe and dangerous and yet it’s a common strategy in many trusts. The comment above from a UK colleague about crowding this winter will be familiar to many. Corralling the risk in an overcrowded ED is indicative of a hospital that has chosen to concentrate the risk in a single place. It’s bad for patients and it’s bad for staff who burn out as they cope with a deeply unfair, grossly differential and unsustainable workload.

My plea is that when we hear talk of avoiding one upping that it does not inadvertently lead to even greater levels of harm in the ED.

We need strong and vocal leadership to stop this from happening.

vb

S

Primary Survey Feb 2017

30 Jan, 17 | by scarley

Highlights from this issue
Ellen J Weber, Editor in Chief

 

Teaching how to think
Somewhere between entering medical school and leaving specialty training, a young doctor makes a transition from being a complete novice to a physician capable of making diagnostic and treatment decisions more or less independently. How exactly does that happen?

Two articles in this month’s issue, along with a commentary by Damien Roland, attempt to shed some light on this murky metamorphosis. The study by Bowen et al examines  a cross-section of clinicians at different phases in their careers, looking at how decisions are made. In this study, 15 Paediatric Emergency clinicians (consultants, trainees and nurse practitioners) were interviewed about their decision making when treating  patients under 5 with respiratory illness. Junior clinicians were more risk averse, and relied heavily on guidelines and second opinions; experienced physicians appeared to use more tacit knowledge and take more risks.

In this month’s Editor’s Choice selection, Adams et al, studied 37 junior EM doctors who were asked to recall two recent cases and discuss how they approached their clinical decision making. In the language of dual-cognition theory, the authors found that the trainees essentially described that throughout the diagnostic and disposition process, they used so-called Type 1 thinking (intuitive), countered by Type 2 (analytical) thinking to keep themselves and their patients safe. A high level of diagnostic anxiety was seen in this group of doctors. The authors suggest that teachers could do more to prevent premature closure, speed up learning of pattern recognition to decrease cognitive loads, and routinely employ methods of reflection after a case to improve awareness of the reasoning process. They provide a helpful set of questions for the teacher of emergency physician to walk the learner through this process. To bring this all together, Dr Roland’s commentary ‘Have we forgotten to teach how to think?’ challenges us all to consider if we are paying enough attention to this aspect of the transition from novice to expert.

Smile, though your heart is breaking
Arguably, the antithesis of thinking is acting on instinct, or gestalt. Much has recently been made of physician gestalt, with several studies suggesting that physician gestalt is about as good as many tests or decision rules. Jeffrey Kline, who most of us know for his work in pulmonary embolism (PE), and specifically the PERC rule, has an avocation in physician gestalt, questioning what it is about our patients that gives us this ‘sixth sense’ about whether they are sick or not. Some will remember Dr Kline’s EMJ publication in which he demonstrated that patients who are sick (in that case, have a PE or a serious cause of chest pain) have less facial reaction to stimuli than those who are well. Based on this finding, he hypothesized that patients who do more smiling – and physicians perceive as smiling – are less likely to have a serious diagnosis. In this month’s issue, we reveal the results of a study by Kline and colleagues of 208 patients about to undergo a CT scan for pulmonary embolism.  The pretest probability of a PE was estimated using the gestalt method (visual analogue scale, 0%–100%), the Wells score (0–12) and physicians’ impression of whether the patient smiled during the initial examination (smile+). Patients’ faces were also analysed with an automated neural network-based algorithm for happy affect. Without being too much of a spoiler, let’s just say ‘don’t let that smile fool you’. The results may have you rethink your initial  impression of that chipper patient in room 3.

Is it time to embrace the Shock Index?
The Shock Index was introduced in 1967 as a prognostic marker for hemorraghic and infectious shock. It has shown promise as a marker of high risk patientsin several ED studies since then, having  an association with increased lactate, and, in another study, increased incidence of post-intubation hypotension. But the Shock Index has not generally been adopted into routine EM practice. Balhara and colleagues from The Johns Hopkins University School of Medicine studied over 58 000 patients seen in their ED over 12 months, and demonstrated that increasing values of the Shock Index were associated with an increasing likelihood of admission and mortality. An SI of >1.2 was a strong predictor of both inpatient admission and mortality. The Shock Index is remarkably simply to calculate: heart rate/systolic BP. If you can calculate a MAP, you can certainly calculate a shock index!

Candy is dandy, but glucose is quicker
This systematic review by Carlson and colleagues answers the question of whether dietary sugars are as good as oral glucose for patients with hypoglycaemia (and no IV). The simple answer is no, they are not. However, knowing the ‘bottom line’ should not dissuade you from reading this interesting paper, which looks at the effects of some of your favourite confections.

bw

Ellen Weber

EMJ Editor

The ‘Deliberate Practice Mindset’

27 Jan, 17 | by rlloyd

Performance improvement is an interest of mine. I have previously blogged and podcasted about the strategies I employed to lift my game (from rock-bottom) when working in an extreme environment – a South African township ED.

I first became aware of ‘deliberate practice’ after reading an excellent St. Emlyn’s post last year. I had never encountered the concept before, but it resonated with me because it resembles certain aspects of how I’ve approached self-improvement in a professional setting, particularly when desperate to prove myself in South Africa.

The psychologist who originally described deliberate practice, Dr. Anders Ericsson, has recently published a book – Peak. It explores the ‘science of expertise’, for which he is the world’s leading expert – the expert on experts.

I thought I’d discuss a few of my take-home points from the book.

The ‘gift’ fallacy

“I am not talented, I am obsessed” – Conor McGregor, UFC lightweight champion

Too often, wider society’s assumption is that elite performers are naturally ‘gifted’. They have been magically blessed with superhuman ability. According to Ericsson, this is false.

No-one is born with an innate ability to perform at expert level, in any domain. All exceptional performers, regardless of field, have had to push themselves through a very intense practice regime to get to where they are. They have learnt how to be brilliant.

Ericsson repeatedly makes the point that in his 30+ years of studying an extraordinarily wide range of expert performers, from grandmaster chess players to professional tennis players to concert violinists, he is yet to encounter a genuine ‘prodigy’ – somebody born with prerequisite skills for expert performance.

MozartEricsson’s favourite example of the ‘God-given talent’ fallacy is legendary composer Wolfgang Amadeus Mozart. From an astonishingly young age, Mozart wowed audiences in concert halls across Europe with his apparent mastery of multiple musical instruments, and was labelled a child prodigy. Not so much, it turns out. The history books reveal that Wolfgang could barely walk before commencing a comprehensive training regime designed by his father, a pioneer in musical training. Furthermore, Ericsson claims that if he were around today he would barely stand out from the crowd. In fact, it’s been demonstrated that Suzoki Method-trained child musicians are often able to perform to a higher level than Mozart was ever capable of achieving.

A key component of Mozart’s prodigious skillset was thought to be his possession of perfect pitch – the ability to accurately name a musical note upon hearing it in isolation. The assumption was that it spontaneously emerged from birth and was un-teachable. It has since been proven that anyone can be trained in perfect pitch, particularly if they’ve received appropriate training between the ages of 3 and 5 years. Intriguingly, it is now acknowledged to be fairly common for children born in countries where tonal languages (e.g. Mandarin) are spoken to possess perfect pitch if musically trained. No magic involved.

The only exception to the rule that natural talent is bogus is when it comes to height and body size. Specific phenotypes are essential for certain sports – you need to be tall to slam dunk a basketball, and being short confers a big advantage for competitive artistic gymnastics. No specialised training regime will lengthen or shorten your bones.

We’re all endowed with the same ‘gift’ – the ability to adapt and improve if we train ourselves correctly (i.e. effective practice). Excitingly, Ericsson’s key message in Peak is that a common set of general principles lie at the heart of effective practice for any human endeavour… all walks of medicine included.

All practice is not equal – avoid naive practice (and forget the 10, 000 hour ‘rule’)

The most common approach to improving performance is ‘naive practice’.

This is where one spends a significant amount of time engaging in the activity, with the hope that stockpiling experience alone will improve performance, and move them closer to the realm of expertise.

“All I need to do is see 15 Majors patients per shift for the next 10 years and I’ll become a world-beating Emergency Physician” – hapless emergency medicine trainee destined for mediocrity

This is aligned with the 10, 000 hours ‘rule’ as per Malcolm Gladwell in his book Outliers. The proposed theory is that 10, 000 hours of generic practice yields expertise, with emphasis on time spent practicing as opposed to the nature of the practice itself. No specific component of the activity is isolated and focused on (e.g. putting in golf, or needle manipulation in central venous access), one just keeps doing the task over and over again. Outliers has been an immensely popular publication, and the 10, 000 rule a widely-disseminated concept. It sounds cool, and it satisfies the basic human desire for cause and effect.

In reality, this theory is fundamentally flawed. In order to change behaviour (i.e. improve performance), you need to engage in effective training. Ericsson calls this ‘purposeful practice’.

Interestingly, it is Ericsson’s original work, examining concert violinists in training, that inspired Outliers, and he levels a reasonable amount of hostility towards Gladwell in Peak, with accusations of corrupting lessons from the research. The best violinists out of the trainee group had all spent approximately 10, 000 hours by the age of 20 in solitary practice, as compared to the more inferior (but still relatively elite) trainees who had a few less thousand hours on the clock. It was this finding which prompted Gladwell to jump to the conclusion that 10, 000 hours was the magic number, yet the few that went on to win international music competitions did so at 30+, when they had put in 20,000 to 25,000 hours of practice.

“The greats weren’t great because at birth they could paint, the greats were great because they paint a lot” – Macklemore, rapper

It might be mired in controversy, but the 10, 000 hour rule does serve one crucial purpose – it reminds us that a massive volume of practice is required to achieve peak performance. No elite performer in any field has not dedicated a significant slice of their life towards achieving their goal. The path to greatness is not easy.

Purposeful Practice (core of Ericsson’s deliberate practice)

Exactly what it says on tin – this is practicing with a purpose. The mission is to improve, and you are practicing for that sole reason. Every time you practice, you are asking the question: “How can I do this better?”

A specific component of the skill is isolated (a component that one is poor at/can’t do) and then targeted for improvement via training activities. There are four principles of purposeful practice:

1.     You need to establish a (reachable) specific goal. Vague overall performance targets like ‘succeed’ or ‘get better’ won’t cut it.

2.     You must be maximally focused on improvement during practice. It must be intense, uninterrupted and repetitive (‘drilling’). Not particularly pleasant, but highly rewarding.

3.     You must receive immediate feedback on your performance. Without it, you can’t figure out what you need to modify or how close you are to achieving your specific goal.

4.     You must get out of your comfort zone, constantly attempting things that are just out of reach.

Take chest drain insertion for example. You isolate one part of the procedure that you know needs improvement – e.g. surgical hand-ties (to suture the chest drain to the skin):

Goal: Be fast and efficient at single-handed surgical hand-ties by the end of the training session.

Focus: Watch a training video explaining how best to perform the tie a few times; then practice tying knots round a kitchen utensil using the taught technique multiple times.

Feedback: Compare your performance to that on the training video, or ideally get personalised feedback from a supervisor.

Exit comfort zone: Experiment by performing the technique under time pressure or give yourself less suture thread to work with.

A hallmark of purposeful practice is that performance level during training tasks is not initially at the desired level – there is a gap. By the end of a phase of training, there needs to be something measurable that you’ve improved.

Embracing these principles in training squeezes the trigger of the greatest weapon in the arsenal of the human brain – adaptability. Every training session should be viewed as a challenge to refine and improve.

Deliberate Practice

“The most effective (improvement) method of all: deliberate practice. It is the gold standard, the ideal to which anyone learning a skill should aspire.” – Anders Ericsson

Deliberate practice encompasses the principles of purposeful practice, with a couple of additional elements:

1.     The field must be well established, and elite performers easily identified.

2.     A coach or teacher guides training.

A good coach provides constant individualised feedback and designs training activities that target specific areas. They hold the ‘roadmap’ that guides the student through an evolving training regime that hones skills in a specific order. Certain skills can only be taught and practiced once others have been mastered.  This calculated and heavily supervised approach to training always leads to elite performance when the student is motivated. It is tried and tested.

A useful analogy is to think of purposeful practice as trekking through the desert to a specific destination that is out of sight. You know the general direction you need to go, but in order to reach the destination you must walk in a completely straight line – notoriously difficult in the desert. A good strategy would be to use landmarks up ahead such as trees and sand dunes to aim at, so as to avoid walking round in circles. You are progressing with a purpose, but there is minimal guidance.

In this context, deliberate practice can be thought of as that same journey, but instead there is a path marking the route you need to walk, with signposting along the way, and even a camel guide to get you back on track if you veer off the route.

Mental representations

Engaging in purposeful/deliberate practice modifies the structure of our brains. Specific neural circuitry, which fires action potentials when training a skill, get reinforced and increasingly complex. This serves to strengthen the ‘mental representations’ one has of the skill in question.

The human brain is a blank canvas, and learning a new skill is like painting a picture on that canvas – the picture being a mental representation of that skill. With effective training, and as one improves at performing the skill, a discernible image starts to take shape. As the years of effective practice roll on, the picture becomes increasingly detailed and animated, and eventually it correlates with performing the skill at an expert level.

The expert performer, via their mental representations, is acutely aware of how best to perform. By comparing what they are doing in the moment with the perfect picture in their head, they can modify their performance appropriately – self-policing. The quality and quantity of mental representations is what sets expert performers apart from everyone else.

“In pretty much every area, a hallmark of expert performance is the ability to see patterns in a collection of things that would seem random or confusing to people with less developed mental representations. In other words, experts see the forest when everyone else sees only trees” – Anders Ericsson

The perfect example of elite performance correlating with highly sophisticated mental representations is George Koltanowski, a chess Grandmaster who set the world record for simultaneous games of blindfolded chess – 34 games (he won 24 and lost 10)!  His mental image was so strong that he could animate each game in his mind without looking at a single chess piece. It turns out simultaneous-game blindfold chess has been a pursuit of Grandmasters for centuries.

Furthermore, in studies of elite footballers and basketball players, it has been shown that when visual stimulus is suddenly removed, they can accurately pinpoint the position of all their teammates and opposition, and even predict how the game evolves in the seconds that follow. Again, this is facilitated by their mental representations – highly detailed images that come to life in the brain of the performer.

Fascinatingly, if you asked a grandmaster to recall the positions of randomly placed chess pieces on a chess board, or asked a footballer to recall the positions of 22 randomly placed men on a football pitch (i.e. not in position as a result of a game), they would fail because their mental representations are specific for the respective activities. If the arrangement of pieces or players is random, it ceases to be meaningful, in much the same way a set of jumbled up words is meaningless in comparison to a sentence.

The ‘deliberate practice mindset’

To truly reap the benefits of purposeful/deliberate practice, one must reject three prevailing myths:

1.     Your abilities are limited by genetics.

2.     If you do something for long enough you’ll get better.

3.     All it takes to improve is to increase your effort levels.

Once this is done, you are set free; the world is your oyster. However, the road to expertise is long and gruelling, and patience is crucial. The four underlying principles of purposeful practice must be kept in mind at all times, and failure should always be viewed as a precious opportunity to reflect and refine one’s mental representations.

If no coach or teacher is available (i.e. deliberate practice not strictly possible), identify somebody who is at a level that you want to reach (i.e. a mentor), try and understand how they got there, and proceed to purposefully practice.

Intense periods of focus, constant repetitions, and hovering at the edge of one’s comfort zone in training will get pretty miserable and frustrating at times. However, it should be appreciated that when quantifiable improvements start to occur, striving for further gains will become more enjoyable… even exciting.

Remember that a crucial aspect of deliberate practice is that it focuses solely on performance (i.e. how to do it) – it is a skill-based practice, and this must be embraced. By effectively practicing components of the skill and building stronger mental representations, knowledge will build naturally alongside. New concepts will seem less abstract as they are absorbed whilst applying skills (NB: This is in contrast to the traditional approach to medical training which has placed more emphasis on knowledge acquisition than skill development, largely because it is more convenient and less labour-intensive to teach).

In medicine?

An unfortunate reality of most medical specialties is that once a practitioner is fully qualified (i.e. a consultant or attending physician) there are few opportunities for immediate feedback on his/her clinical practice. There are no longer regular mandatory appraisals, and too often, little feedback from the patients themselves (e.g. a radiologist might not be made aware of the outcome of a patient where a cancer was missed on CT scan).

Furthermore, as seniors are no longer being actively trained, it is very unusual for them to be pushed out of their comfort zones, and they will usually deem their own performance level to be ‘acceptable’. You might say that they are particularly guilty of naive practice. This is a recipe for stagnation, and an overall decline in performance. An interesting passage in the book is where Ericsson discusses research into senior radiologists looking at mammograms, and experienced GPs listening to heart murmurs. It turns out their diagnostic accuracy is no better (and in some cases worse) than their junior colleagues, who will have received more recent active education.

As an emergency medicine trainee, much of my daily work will embrace the principles of deliberate practice, but it is variable, and often depends on the boss I happen to be on shift with. Taking ownership is key. It’s up to me to be cognisant of what elements of practice will make me a better doctor, and anchor my training appropriately. Awareness of these principles has also given me a greater appreciation of the utility of simulation training – ‘off-the-job-training’ which focuses on closely supervised skill development rather than knowledge acquisition.

It will be far more of a paradigm shift for senior doctors (i.e. finished all training) to adopt deliberate practice, but the implications for patient outcomes, and indeed medicine’s overall trajectory, will be enormously positive if they do.

I highly recommend Peak to anyone interested in improving at what they do. Doctors, of all grades, should be aware of, and striving to incorporate, the lessons from Anders Ericsson’s masterpiece.

Robert Lloyd
@PonderingEM

*This blog first appeared on the Pondering EM blog

The 4-hour standard. Why can’t you get it right?

10 Jan, 17 | by scarley

please-get-it-right

If you were hoping for a solution to flow in the ED then this is not the post for you. Rather it’s an appeal and a cry of pain from all UK clinicians who work in emergency departments for politicians and journalists to understand what the 4-hour target is.

It is the percentage of patients seen and DISCHARGED OR ADMITTED within 4 hours.

Journalists regularly mistake this as the time that people wait to be seen in the ED which of course is entirely different. Yesterday Jeremy Hunt was questioned in the commons about the current crisis in the ED and even the opposition front bench mistook the 4 hour standard as wait to be seen and not the time it takes for us to completely sort patients out and either get them home or into a hospital bed.

Even Wikipedia is unclear on the matter, and so it’s perhaps not surprising that everyone is confused. The King’s fund does much better and has some excellent research in the area.

Does this matter? Well I would argue that it does. From a public perception if we are failing to even assess people within 4 hours that does indeed sound awful. The idea that we have to complete the ED journey within 4 hours must surely be understood as a more challenging task. If it were just a wait to be seen then in all honesty we’d be running at well over 100% already (if you include triage which you should).

So. An appeal that perhaps no journalist or politician will read. Please get it right and stop emergency clinicians shouting at the TV or radio every time you get it wrong. We’re under enough stress as it is.

vb

S

@EMManchester

https://twitter.com/deanoburns/status/818745470281465856

Primary Survey January 2017

1 Jan, 17 | by scarley

Highlights from this issue

Simon Carley, Associate Editor

Another fabulous year in Emergency starts with a new world order and new challenges for EM and prehospital care wherever you are in the world. This month our contributors tackle systems, cases, prognosis, analgesia, urine collection and more. Here’s the highlights.

Graphic

Scoring systems and nurses intuition

I’ve always been told to trust the nurses judgment, and in truth it’s got me out of trouble many times, but this intuition, gestalt, judgment is difficult to define. Allan Cameron looked at this whilst comparing nursing views on need for admission against a structured score (the Glasgow admission prediction tool). The bottom line is that nurses don’t do as well overall at predicting the need for admission, but if they are sure about their opinion then you’d be courageous (aka foolish) to ignore it. It’s good to see more work on how we make decisions in the ED as after that’s what can make huge differences to patient outcome.

Critically ill children and medication timings

Kenneth Michelson and colleagues at the Boston Children’s hospital have looked at how the presence of really sick patients impacts the care of others. I suppose this is intuitive as we know that the seriously ill or injured suck up the finite resources of the ED, and this study tries to quantify this in terms of medication timings. In essence they have shown that small but significant differences in time to crucial medications (such as antibiotics or steroids) occur if a patient is exposed to the presence of another critically ill child in the ED. It’s another lesson that EM requires a team, and that team has a finite capacity.

A wee wait for a wee wee

How I wish this trial was Scottish so that they could have used that title. Alas no, this paper on urine collection is from Adelaide, Australia. If you work in paediatric emergency medicine then you will know that waiting for urine is a common reason for patient delays. Jonathan Kaufman and colleagues looked at a method to augment this by placing a saline soaked gauze in the supra-pubic area in kids aged 1 month – 2 years. They managed a 30% success within 5 minutes, which is impressive although there was no control group and smallish numbers. The effect of temperature is unclear, but they are looking at this and we may learn more in the future.

Predicting exit block

Winter pressures are already being felt in the UK with many departments feeling the pressure of patient numbers and poor flow through the ED. Sue Mason and colleagues have produced a rapid evidence review that may be very helpful in the next few months. Amazingly, despite the huge impact on our departments there is a paucity of data out there on effective interventions and very few from the UK. This paper sets out the evidence base as it exists and we should all familiarize ourselves with it. As for solutions? Then this paper won’t deliver that but it is a call for further work (and let’s face it we’re not short of situations to study here in the UK).

Lis Franc fractures review

Simon Lau and colleagues bring us an update and review on Lis-Franc fractures. This is an injury I’ve seen missed several times during my career, some of which have resulted in poor patient outcomes. Even with digital radiology and rapid reporting a few seem to slip through the net and so this is a welcome paper. There are some top tips in here, especially for those injuries with limited radiological signs. Well worth a read and a basis of a good teaching session in your department.

Stopping resuscitation in pre-hospital traumatic arrest

When I started training the resuscitation of traumatic cardiac arrest was considered to be akin to resurrection but times have changed and a much more aggressive approach has led to many survivors from blunt and traumatic injury. Deciding on futility is tricky and this month we publish a paper from Taiwan that uses a database of cardiac arrest outcomes to determine a rule for terminatint resuscitation efforts. In brief the presence of blunt trauma plus asystole is considered futile. However, we don’t know if that is a self fulfilling prophecy. If no efforts are made then a poor outcome is inevitable and a circular argument ensues. Retrospective studies always struggle with this conundrum so have a read and form your own view.

Long term outcome from traumatic cardiac arrest

More on what happens to patients following a traumatic cardiac arrest from our French colleagues. Francois-Xaview Duchateau and fellow researchers examined the Traumabase dataset to look at the neurological outcomes amongst survivors. Overall the results are encouraging and support the aggressive approach to managing these patients. Of note 90% were victims of blunt trauma which makes this month’s paper from Taiwan as many of the survivors were in asystole when the EMS teams arrived (which might apparently deem them un-survivable by their proposed tool). Clearly we need to read these two papers in tandem and carefully consider the discussion in this French paper. The bottom line appears to be that we still don’t quite understand traumatic cardiac arrest, but that it is not a lost cause. Another superb month in the EMJ.

Don’t forget to keep in touch between paper editions with the EMJ Blog and Podcast accessible through the journal website at http://emj.bmj.com

EMJ blog homepage

Emergency Medicine Journal blog

Analytical approach to the developments and changes in the field of Emergency Medicine Visit site



Creative Comms logo

Latest from Emergency Medicine Journal

Latest from EMJ