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Primary Survey June 2017.

8 Jun, 17 | by scarley

This month’s editor’s choice is actually a pair of papers: one, a study on the diagnostic characteristics of the T-MACS chest pain risk stratification score AND the other, a paper explaining a key methodological concept used in this and other studies of diagnostic tests, the receiving operator characteristic ROC) curve (Richard Body (an associate editor of EMJ) and colleagues previously developed the MACS rule, which classifies patients as very low risk or very high risk after the results of an initial set of biomarkers are known, TMACS relies on obtaining both high sensitivity troponin and heart-type fatty acid, but the latter biomarker not widely available. A modified rule, the MACS score, uses only high-sensitivity troponin and in the current study the authors evaluate this new rule’s test characteristics, using the ROC curve. Hui Zhe Hoo, Clinical Research Fellow at the University of Sheffield and a respiratory physician, explains the fundamentals of the ROC curve using this paper as an example. This is the third in EMJ’s occasional series of articles explaining statistical concepts frequently found in the emergency medicine literature.

Still a cinderella service

Demand for mental healthcare in the ED continues to rise. Sadly this rise increasingly includes children and the provision of child and adolescent mental health services (CAMHS) in most emergency departments falls well short of what is needed. Thus, a systemic review in this issue by Newton and colleagues from Canada on children’s mental health crises in the ED makes interesting reading. A previous review undertaken by these authors in 2010 provided some evidence to support the use of specialised care models to reduce hospitalisation, return ED visits and length of ED stay. In the current study they report increase in research over the past few years, yet most of the evidence is limited by weak methodology. It is evident that the specialised resources and skills needed are still not readily available and the authors reiterate the need for high quality evidence to guide mental health screening, early and effective interventions and on-going follow-up care after an ED visit. I suspect few of us would dispute this view.

Ladders or smiley faces?

Accurate assessment of pain due to an acute injury can be challenging especially when the child is distressed and anxious, but providing timely and effective analgesia is key to child and carer comfort and satisfaction.This issue includes an interesting paper by Ffion James and colleagues from Wales who set out to assess the inter-rater agreement of the Royal College of Emergency Medicine (RCEM) composite pain scale. The majority of pain assessment tools for children were designed for post-operative or chronic pain and not for sudden and acute pain due to injury. The RCEM composite tool combines the numerical rating scale (Ladder), a modified Wong –Baker Faces Pain Scale (Faces scale) and a Behaviour score which groups pain into four categories based on severity. To date the reliability of this scale has not been assessed. In their study, pain severity was assessed by the triage nurse doctor and child (depending on their age) using the composite pain scale. The Faces Scale demonstrated greater inter-rater agreement than the Behaviour Scale, while the Ladder demonstrated poor inter- rater agreement in comparison with the Behaviour score. The authors conclude the Ladder score could be omitted from this composite tool.

Using emergency data for public health interventions

Two studies in this issue demonstrate how data from emergency care can be used to inform public health interventions. Acute and chronic alcohol intoxication, a worrying global public health issue, is the cause of many health and social problems. Reunion Island in the South West Indian ocean is no exception. Reunion Island is among the four French regions where premature mortality due to alcoholism and cirrhosis is the highest and foetal alcohol syndrome is seven times higher than that of metropolitan France. Vilain and colleagues undertook an exploratory analysis based on syndromic surveillance data to describe the emergency department visits for alcohol intoxication and factors associated with their variation. Alcohol intoxication attendances were the second most common reason for ED attendances after trauma and these attendances increased significantly on benefit payday, weekends and public holidays. The authors conclude this kind of syndromic surveillance system for monitoring public health data other than infectious diseases can be used to inform initiatives to reduce morbidity and mortality from alcohol intoxication.

According to the WHO, interpersonal violence accounts for around half a million deaths a year globally. This figure will come as no surprise to ED clinicians and may even be regarded as conservative by those caring for victims on a daily basis. Addressing violence has traditionally been a police concern, so it was interesting to read of a cross sectional study by Quigg and colleagues in the UK which explored the potential of ambulance call out data in understanding patterns of violence to inform prevention activity. This paper is well worth a read as ED’s will see similar trajectories and trends. The majority of call outs were at night for young males in deprived and urban areas, and these calls increased on weekends and bank holidays but not for sporting events. 77.3% were assault/sexual assault while 22.7% were stab/gunshot/penetrating trauma. Interestingly, there were significant differences in call out characteristics between the two violence types. The authors conclude that ambulance call out data provides a rich source of information and sharing this data could be key in violence prevention programmes. Any information that can contribute to violence prevention programmes has to be worthy of consideration.

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Mary Dawood

 

‘My Mental Toughness Manifesto’ Part 4: PROCESS

30 May, 17 | by rlloyd

passenger-plane-landed-in-hudson-river-136395463010203901-150114153840

Everything in aviation we know because someone somewhere died… We have purchased, at great cost, lessons literally bought with blood… We cannot have the moral failure of forgetting these lessons and have to relearn them.”

Sully Sullenberger
Pilot of Flight 1549, ‘The Miracle on the Hudson’

All frontline healthcare warriors will bear scars from emotionally distressing experiences in the workplace (e.g. major incidents with multiple casualties, unsuccessful paediatric resuscitations, personal mistakes resulting in patient harm). For the most part, members of the public will only rehearse being exposed to these flavours of horror by watching movies or having nightmares. For us, it is a potential reality every shift.

In the aftermath, the way one processes these events heavily influences future commitment to similar causes and cognitive appraisals (challenge vs threat mindset) – the key determinants of mental toughness.

Adaptive processing should incorporate ‘Black Box Thinking’ and self-compassion. 

‘Black Box Thinking’

BBT betterConsider the aviation vs healthcare discussion for a moment – arguably the two most safety-critical industries in the world.

On average, just one commercial flight goes down for every 8.3 million take-offs worldwide. In the US alone, there are approximately 400, 000 avoidable medical errors every year, which is the equivalent of two jumbo jet crashes every day [1, 2]. That is a gargantuan discrepancy in passenger versus patient safety.

Of course, it is well documented that the two industries are not directly comparable. There are far more reasons for a patient to die than there are varieties of plane crash, and medics do not yet have the option to switch on a mental bandwidth-sparing machine that’s able to mop up routine tasks. Nonetheless, the statistics illustrate an indisputable point – we have a huge amount to learn from our aviation counterparts, whether we like it or not.

Why is aviation such a staggeringly high performance industry? The answer is simple: there is an institutional culture of learning from failure. Every plane is equipped with two sturdy black boxes which record conversation in the cockpit, and electronic decision-making (i.e. which buttons were pushed). In the case of an accident, the black boxes are promptly retrieved from the battered fuselage, opened, and the contained data interrogated. Every aspect of the crash gets the fine-tooth-comb-treatment to identify exactly what went wrong. Protocols are subsequently modified so the same mistake can never happen again. Error is not viewed as a sign of weakness or inadequacy – on the contrary, it is treated as a precious (even exciting) learning opportunity for everyone who might benefit.

Healthcare culture is largely the polar-opposite. Failure is stigmatised because doctors are supposed to be infallible in the eyes of the public. Mistakes get ‘swept under the carpet’ by the guilty to avoid being held accountable and where that is not possible, the blame-game ensues [3]. When one’s professional credibility is at stake, a successful escape from the situation is higher up the priority list than learning from the failure; and the omnipresent threat of litigation only serves to further entrench this defensive, maladaptive institutional culture. The immediate gratification of reputation-preservation trumps the potential for professional growth that naturally follows acknowledgement of personal failure. We routinely blind ourselves to the best possible signposting for getting better at our jobs – our mistakes.

Whilst this growth-stunting phenomenon will vary in severity across the spectrum of healthcare environments, you would be hard-pressed to find a doctor, anywhere in the world, not regularly exposed to this embarrassing peculiarity of our profession.

Be a black box thinker. Own your mistakes. Share your lessons. Interrogate every performance with the curiosity and tenacity of the Air Accidents Investigation Branch. Re-conceptualise your relationship with failure so that it no longer represents an existential threat, but acts as a guide for your ‘practice’ phase.

‘Reflective practice’ is an overused and misunderstood term in medical training (in my opinion). Often, written evidence of it is a requirement for career progression, and when one ‘reflects’ for that reason alone, it ceases to be useful. Furthermore, documented reflections will too frequently centre around what went well – a less lucrative training exercise.

Apply the black box philosophy to your reflective practice and force yourself to face potentially ugly truths. Embrace being criticised and never back down from asking a ‘stupid question’ – it tees you up for focused training and subsequent accelerated improvement. Have the bravery to be the detective leading the warts-and-all investigation on yourself.

Self-Compassion

In frontline healthcare, we are routinely exposed to life-changing injury and acute illness. If we take our workplace goggles off, and dare to view the worst aspects of our jobs through the eyes of a ‘normal’ person, it can be intensely disturbing. Furthermore, subscribing to the highest professional standards can make us prone to gratuitous suffering as we’ll mistakenly convince ourselves that we could have done more for unsalvageable patients. Our keenness to take full responsibility can render us vulnerable to unnecessary self-punishment.

Without appropriate perspective and personal support, our view of the world, and indeed of ourselves, can become warped. Long-term self-neglect in our line of work will eat away at our commitment to the job, potentially invite long-term psychological damage (PTSD), and ultimately, harm our patients.

When a particularly traumatising incident occurs, many institutions will employ a ‘critical incident stress management’ (CISM) protocol, which encompasses a range of supportive interventions aimed at preventing PTSD [4]. This includes a formal group debrief, led by an outside party (usually a psychologist), within 72 hours of the event. Despite being widely practiced, this approach is controversial as no definitive benefit has been demonstrated in the literature. However, widely accepted to be of critical importance for psychological wellbeing in the immediate aftermath of an emotionally traumatising incident is a ‘defusion’ process [4, 5, 6].

‘Defusion’ is a team get-together where thoughts and feelings are shared in confidence. When threat appraisals drench our brains in cortisol and distort our perceptions, defusion allows for piecing together the chronology and specifics of the event through organic, informal discussion with team-mates. It is an opportunity for emotional support, having a collective laugh/cry at the absurdity of the job, and an accurate information gathering exercise in a safe environment. The team pull together in the aftermath, are honest about their emotional frailties, and find strength in each other. It lacks the rigidity and intrusion of an uninvited formal debrief led by an ‘outsider’.

Pain shared = pain divided

Joy shared = joy multiplied [7]

In the hospital setting, it can be as simple as insisting on a chat in the coffee room after a big resus, or a quick get-together after work. It might seem minor, but unnecessary guilt, anger, confusion and other damaging emotions can be thwarted by this process. However informal and insignificant it might appear on the surface, it is of fundamental importance, and must be sought out, however logistically difficult.

In more extreme environments, such as combat or the prehospital setting, sitting down to defuse should also be used as an opportunity to regain a feeling of physical safety, get warm, hydrate and refuel (eat something).

Self-compassion via defusion is a critical strategy for building mental toughness. Taking care of yourself and your team after an acute insult preserves commitment to the job, and prevents lasting psychological scars that will render you less able to cope emotionally with the inevitable acute stress that lies in wait.

Summary

Use mistakes as signposts for self-advancement as opposed to sources of embarrassment. Own your failures instead of hiding them, and use them to guide your ‘practice’ phase.

Always remember to ‘defuse’ with your team after emotionally challenging cases/incidents. Share the pain, and multiply the joy. Never underestimate the therapeutic value, and heavy dose of perspective, that humour offers.

‘My Mental Toughness Manifesto’ Roundup

You are mentally tough if able to state the following (Part 1):

“I am 100% committed”

“I feel challenged”

To build and maintain mental toughness, I propose seven strategies over three phases of the game:

‘Practice’ (Part 2)

  • Immersion
  • Deliberate Practice
  • Visualisation

‘Perform’ (Part 3)

  • Tactical Breathing
  • Cognitive Reframing

‘Process’ (Part 4)

  • ‘Black Box Thinking’
  • Self-compassion

Own your performance.

Robert Lloyd
@PonderingEM

References

  1. Black Box Thinking. Matthew Syed.
  2. 2017 Royal Society of Medicine Easter Lecture: Creating a high performance revolution in healthcare. Matthew Syed.
  3. What do Emergency Medicine and Donald. J Trump have in common? Robert Lloyd, EMJ Blog.
  4. Mental health response to disasters and other critical incidents. BMJ Best Practice.
  5. Debriefing and Defusing. http://www.davellen.com/page21.htm
  6. Shoes, Sex and Secrets: Stress in EMS. Ashley Liebig. SMACC Chicago lecture.
  7. Grossman, L.C.D., On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. 2008: Warrior Science Publications.

‘My Mental Toughness Manifesto’ Part 3: PERFORM

9 May, 17 | by rlloyd

‘Practice’ is about building a skillset, and fostering a way of life (via ‘immersion’) that serves to strengthen perception of one’s available resources when crunch time arrives.

However, reality dictates that certain scenarios are impossible to prepare for, particularly in the emergency medicine arena. The more chaotic the workplace, the higher the frequency of unavoidable threat appraisals.

Therefore, it is crucial to utilise strategies which stabilise one’s level of emotional arousal in the heat of battle. Namely tactical breathing and cognitive reframing.

Tactical Breathing

“Feel breath filling every cell of your body. This is our ritual. We master our breath, we master our mind. Pulling the trigger will become an unconscious effort. You will be aware of it, but not directing it. And as you exhale, find your natural respiratory pause and the space between heart-beats.”

American Sniper

In a high stakes game, where your next move (performance) has implications for the survival of another human being, it is a guarantee that your sympathetic nervous system will be working overtime. We know, of course, that this can work in our favour if challenged (perceived resources > demands); indeed, we’ll feel ‘pumped’ and ‘ready for action’. On the other hand, this heightened physiological arousal can be the architect of a catastrophic blunder if threatened (i.e. demands > resources; see MMTM Part 1 for a full explanation).

The only component of the autonomic nervous system that we can override and take conscious control over is our breathing [1, 2].

Deliberately slowing respiratory rate in a moment of crisis has the effect of preventing further escalation of other features of the sympathetic surge, such as tachycardia and hypertension. This feeling of control over our physiological arousal induces a prevailing sense of clarity and calm. It serves to psychologically detach the conscious self from the stressful moment, allowing an imaginary reset button to be pressed with subsequent restoration of mental bandwidth. Visual and auditory perceptions widen as the mind is released from the paralysing effect of the cortisol dump. Professional presence in the moment is re-established.

square breathing

‘Tactical breathing’ (or ‘square breathing’) describes the four-second method pioneered by Lt. Col. Dave Grossman, of On Combat fame [3]. One must breathe in for four seconds, hold for four, exhale for four and then hold again for four, on repeat until the desired effect is achieved. Whilst this provides the stressed individual with a mental model to follow, it is not essential to adhere rigidly to the timings. The crucial task is committing to a conscious slowing and deepening of one’s breathing cycle.

This idea is nothing new or revolutionary. Breathing techniques have been utilised by elite soldiers, martial artists, professional athletes, and a host of other world-beaters for generations [4]. Underestimate this tool at your peril.

Cognitive Reframing

A salient feature of the threat mindset is a thinking pattern polluted with self-doubt and persecution.

‘I can’t do this’ 

‘I don’t know what to do’ 

‘My mind is blank and my patient is dying’

Naturally, this has a devastating effect on performance. If you are telling yourself that you’re not up to the job, it is highly unlikely that you will prove yourself wrong.

Pressing ‘control/alt/delete’ on these thoughts, and inserting useful content, is therefore critical. This process is called cognitive reframing, and it can be achieved via positive self-talk and an ‘incrementalsteps’ approach.

Positive self-talk

This is the process of forcing one’s internal dialogue to suggest something positive. It can jolt the mind out of a persecutory spiral, if sufficient commitment/buy-in is present [5, 6].

It can be generally motivational:

You have trained well for this’

You’ve been in this position before and succeeded’ 

‘Relax and focus’

Or be used as a method for directing cognitive resources to something specific:

Slow is smooth, smooth is fast’ 

You have plenty of time, just bring the epiglottis into view’ 

Positive self-talk synergises well with tactical breathing, providing, in effect, a two-pronged intervention on physiological and cognitive over-arousal.

An ‘incremental-steps’ approach

During a crisis or particularly demanding scenario, it is always a bad idea to look at the big picture.

Break down the required process into its component parts, and focus only on your first step. Upon completion of that step, allow yourself to contemplate the next, and so on. This will modify your perception of the situational demands by reframing the scenario into a series of manageable challenges instead of one giant threat, and in doing so, hold off any detrimental physiology [7].

For example, if confronted with an unconscious head injury patient who is obstructing his airway and gargling blood, do not allow yourself to contemplate the overall objective (i.e. getting the patient safely anaesthetised and intubated). First focus solely on applying high-flow oxygen, appropriate monitoring, and allocating team roles. Next, focus on achieving intravenous access, followed by readying the airway equipment and drugs, then instrumenting the airway, thereafter ‘epiglottoscopy’, and so on. A state of panic is warded off by a refusal to allow the mind to wander too far forwards.

If you avoid looking at the mountain peak, and focus exclusively on the first obstacle lying in front of you, you will arrive at the summit in no time.

Use positive self-talk to encourage and guide you through each incremental step.

Summary

  • Threat appraisals are an unfortunate inevitability for all acute care clinicians.
  • Taking conscious control over your respiratory cycle grants you the ‘keys’ to the rest of your autonomic physiology.
  • Positive self-talk intervenes on persecutory thought pollution, and can redirect cognitive resources to specific tasks. It can synergise with tactical breathing as a method for ‘resetting’ in a moment of high stress.
  • An incremental-steps approach converts a significant threat into a series of manageable challenges.

In the fourth and final instalment of My Mental Toughness Manifesto, I’ll be discussing a healthy and progressive methodology for PROCESSING a highly stressful clinical encounter after the event.

I’ll leave you with NAVY Seal Commander Jocko Willink’s take on cognitive reframing:

References

  1. Mike Lauria. Enhancing Human Performance in Resuscitation Part 3 – Performance-Enhancing Psychological Skills. EMCrit Blog. Published on November 22, 2015. Accessed on May 5th 2017. Available at [https://emcrit.org/blogpost/performance-enhancing-psychological-skills/].
  2. Seppala, E.M., et al., Breathing-based meditation decreases posttraumatic stress disorder symptoms in U.S. military veterans: a randomized controlled longitudinal study. J Trauma Stress, 2014. 27(4): p. 397-405.
  3. Grossman, L.C.D., On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. 2008: Warrior Science Publications.
  4. Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business.
  5. 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/].
  6. Tod, D., J. Hardy, and E. Oliver, Effects of self-talk: a systematic review. J Sport Exerc Psychol, 2011. 33(5): p. 666-87.
  7. Rob Orman, Rich Levitan, ERCast – Psychology of the Difficult Airway, 2014

‘Why tomorrow’s patient needs a digital NHS’

6 Apr, 17 | by rlloyd

On February 22, the EMJ blog team were well represented at . This was the one-year ‘summit’ of DigitalHealth.London, an organisation (funded in large part by NHS England) designed to accelerate the uptake of digital technology in the NHS. It was part-conference, part-showcase of some potentially game-changing innovations/innovators that are starting to gain traction in global healthcare. The event was hosted by the Royal College of GPs, and it brought together NHS leaders, senior clinicians and digital entrepreneurs. I had the great honour of compèring proceedings.

The event sizzled with excitement and ambition. Conference delegates were talking about the future of the NHS in positive, expansive terms with an up-beat chirpiness that starkly contrasts the doom-and-gloom-ridden water cooler discussions currently reigning supreme across UK hospitals. The air of possibility and optimism was utterly infectious. I had a great time.

I am a now a fully-fledged digital health believer, and adoption of new technologies discussed at the event can’t come soon enough in my opinion. Interventional virtual reality? Artificial intelligence-augmented clinical decision-making? Healthcare provision to every human being on Earth via smartphones? Yes please.

I met some great people, including the inspirational Molly Watt (one of the most accomplished public speakers I’ve heard; if you haven’t heard her story, check out her website – phenomenal stuff), director of digital experience at NHS England Juliet Bauer, and the amazing Dr. Keith Grimes – a GP from Eastbourne and digital health evangelist, whose work I have admired for a while now. He gave a typically superb talk on the application of virtual reality in medicine, and has since written an insightful blog post reflecting on the artificial intelligence panel discussion. Watch this space for a future collaboration between Keith and the EMJ blog team.

DigitalHealth.London have put together a neat full write-up, and produced a couple of beautifully shot videos of the summit, which I happen to feature in! Here they are:

Needless to say, you can count on some future EMJ blog posts exploring digital transformation in healthcare!

Thank you DigitalHealth.London (in particular James Somauroo, Yinka Makinde, Rebekah Tailor, and Hannah Harniess) for inviting me to be involved in your fantastic event.

It’s a great time to be a doctor.

Rob
@PonderingEM

‘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.

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

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

How to write off your paperwork. EMJ Blog.

29 Dec, 16 | by cgray

how-to-write-off-your-paperwork

Emergency medicine is one of those specialities where physicians of all grades have to make their own notes, even the consultants. Medical and surgical bosses have juniors to scribe at the ward round, secretaries to type up dictated clinic letters, assistants to type op notes (most of the time). EM consultants, like their junior colleagues, still need to put their own pens to paper, or fingers to keyboard.

There are two general ways to make notes in the ED. You can do it whilst talking to the patient, which creates the most contemporaneous notes, allows you to use the patient’s own words, and means you can easily recant the story back to them to confirm details, though can sometimes create the impression that you aren’t giving the patient your full attention. I am a big fan of this approach, writing quickly means I can document almost as fast as I can talk. In my opinion, I forget fewer questions, meaning I can carry on with other tasks without having to return to the patient when I remember later on. It’s an approach that works well for me and my very short attention span, though only really works when I’m in a department with paper documentation. Alternatively notes can be completed after seeing the patient, when you can rearrange everything you have learnt into a sensible and concise narrative. However, writing at the desk puts you in the line of fire of technicians asking you to check ECGs, or other colleagues asking your opinion on their patients, to name a few examples. These interruptions have the potential to cause confusion in the history and examination you are trying to commit to paper, and details can be missed or altered.

I would miss doing my own paperwork in the emergency department – I write small and fast, (and reasonably legible) and my note taking helps to put my thoughts in order to make differentials and come to conclusions. However, I’m sure many of you have wondered how much quicker and efficiently you could work if you had someone to write notes for you. Maybe you even have a scribe – I know of people that do, and it seems to be reasonably popular in the US.

Scribes can help those who adopt either approach, and whether electronic or paper. They allow contemporaneous note taking, so that the clinician can focus on the patient, listening to their answers carefully rather than just planning the next question. It can be easy to miss cues from the patient when you are documenting at the same time. They also mean that time isn’t spent documenting at the nurses station, allowing a better focus on other tasks – not missing that subtle MI on the ECG you’ve been shown because you’re still trying to remember how to spell “Sjögren’s”. However, as I’ve already mentioned, sometimes you need to write the notes yourself, for those more complicated patients where writing it out helps with problem solving.

In this month’s EMJ, Katherine Walker and team from Melbourne have put together an observational study and cost analysis to determine the feasibility of training medical scribes in the ED. They took 10 trainees, put them through a 1 month pre-work course followed by 2-4 months of training and clinical sessions facilitated by emergency physicians. Only 5 trainees became competent, and required 68-118 hours of clinical work to do so. They found training scribes to be a feasible exercise, and crucially did not find any loss of productivity in the physicians who trained them. Medical students became competent more quickly than pre-med or non-medical students, and only medical/pre-medical students made it through the whole programme. There is little information on how scribes were selected to go forward to each part of the scheme, and also what the criteria were for applicants to be offered an interview. There was an overall loss in money from the programme, which had not been recuperated by the end of the study. Longer periods of observation would be needed to identify how long it would take for training costs to be outweighed by productivity savings, if at all.

As always we’d recommend you read the paper yourself to get the full results and to be able to draw your own conclusions. A reply from a senior scribe, Nicholas Rich, also provides a useful commentary and some further reading.

It’s an interesting concept, one that doesn’t appeal to me personally, but maybe it does to you. Have you got a scribe? Do they improve your productivity and patient interaction? We’d love to know.

vb

Chris
@cgraydoc

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